Client Information in Euless, TX | Airport Freeway Animal Emergency Hospital

HAVE YOU BEEN HERE BEFORE WITH THIS OR ANY OTHER PETS?*

Yes
No

Client Information

Name*

First Last

Spouse or Roommate

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone*

Alternate Phone

Email

Driver's License and State

Patient Information

Pet’s Name*

Species*

Dog
Cat

Breed

Color

Age*

Sex*

Male
Female

Spayed/Neutered*

Yes
No

Current on Vaccinations*

Yes
No

Current on Heartworm Prevention*

Yes
No

Pet’s Primary Veterinarian or Clinic*

Pet’s Presenting Problem*

PAYMENT IN FULL IS DUE AT THE TIME OF SERVICE

Professional fees are to be paid at the time services are rendered. Please read carefully; a signature is required before examination or treatment will be given.

I certify that I am at least eighteen (18) years of age or older and am the owner or authorized agent for the above listed pet. I hereby consent and authorize Airport Freeway Animal Emergency Hospital LLC (AFAEH LLC), and its doctors, employees, and representatives to administer such treatment, diagnostic, surgical and anesthetic procedures as they deem necessary. None of the above will be held liable or responsible in any manner whatever, under any circumstance for the care, treatment or safekeeping of the animal described above, as it is thoroughly understood, I assume all risks.

I hereby certify that I have read and fully understand the above authorization for medical and/or surgical treatment. I also verify that no guarantee or assurance has been made as to the results that may be obtained. Further, I assume financial responsibility for all charges incurred to patient, consent to release of medical information, and authorize direct payment to AFAEH.

OWNER/AGENT*

First Last

Date*

Email

This field is for validation purposes and should be left unchanged.