Hospitalization Form - Lone Mountain Animal Hospital

Please only use this form if directed to by a member of Lone Mountain Animal Hospital’s staff as this form is used to authorize us to hospitalize your pet.

Pet Information

Pet's Name (required)

Pet's Breed (required)

Pet's Sex (required)

Pet's Age (required)

I, being a person over eighteen years of age, hereby give my consent to admit into the LONE MOUNTAIN ANIMAL HOSPITAL my pet for the following reasons/procedure(s):

Reason/Procedural Information (required)

Contact Information

Owner's Phone Number (required)

Owner's Email Address (recommended)

Emergency Contact Name (recommended)

Emergency Contact Phone (recommended)

Emergency Contact Email (recommended)

Declaration

I am the owner of the above-mentioned animal. I have discussed the reasons for my pet's hospitalization with a veterinarian and I am satisfied with the plan of management for my pet's condition. I have also had the likely fees explained to me and accept responsibility for payment of these fees at the time of my pet's discharge.

While my pet is in the LONE MOUNTAIN ANIMAL HOSPITAL receiving treatment I agree to indemnify the LONE MOUNTAIN ANIMAL HOSPITAL its servants or agents, from any loss or liability which they may incur as a result of any inaccuracy whether intended or otherwise in this, my solemn declaration.

Pet Owner's Signature (required)

Today's Date (required)