Admission Form Pet Name*Owner* First Last Date Of Appointment* Date Format: MM slash DD slash YYYY Please leave 2 telephone numbers where you can be reached today:*What is the reason for today’s visit?*When did your pet eat last?*Did your pet receive their medication(s) this morning?*YesNoN/AIf no, when did they receive their medication(s) last?Additional Information*I, the undersigned, certify that I am the owner, or authorized agent for the owner of the animal described above. I authorize the veterinarian and assistants of Mahomet Animal Hospital to perform the procedures listed above. I release Mahomet Animal Hospital and its associates from any liability in such an event, i.e. injury, escape, death, or any other unforeseen circumstances. I also understand that no guarantee of successful treatment can be made. In the event of an emergency I authorize the veterinarian and assistants to provide any and all treatments/procedures deemed necessary and accept responsibility for any additional cost incurred. (Signature)*Date* Date Format: MM slash DD slash YYYY Account balances will be charged a $1 statement handling fee and 2% interest accrued monthly.CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.