Client's Name (required)
Pet's Name (required)
Contact phone number for you during your pet's stay (required)
Please leave this field empty.
By checking this box, I authorize the doctor to treat my pet as necessary should he/she be unable to contact me at the number(s) provided. (required)
In the space provided, please briefly describe the reason for your pet's exam and any problems/concerns/health issues that may need addressed by the veterinarian:
After your pet is examined, the doctor or technician will call and discuss any further diagnostics or treatment. If you are unable to be reached, the veterinarian will treat the pet as he/she feels necessary for any health conditions needing addressed immediately.
By checking this box, I am giving consent to the veterinarians of Cheat Lake Animal Hospital to examine and treat any emergency conditions. I also acknowledge that I understand the information on this form AND the special notes explained above. (required)
Please type your name here in place of a signature (required):