Admission Form in Mahomet, IL | Mahomet Animal Hospital

Pet Name*

Owner*

First Last

Date Of Appointment*

Please leave 2 telephone numbers where you can be reached today:*

What is the reason for today’s visit?*

Did your pet eat this morning?*

Yes
No

When did your pet eat last?*

Did your pet receive their medication(s) this morning?*

Yes
No
N/A

If 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*

Account balances will be charged a $1 statement handling fee and 2% interest accrued monthly.

Name

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