Driving Park at Flint Animal Hospital

161 Park Rd. Columbus, OH 43235 614-846-8301

Treatment Authorization and Release (of pet(s) listed on page 2)

1. To my knowledge the animal listed above is in good health. I acknowledge the fact that all pre- and
post-operative care is my responsibility.  I am the owner and responsible party of the pet(s) and have
the authority to execute this consent.

2. I understand that if my pet is aggressive and requires extra medication, or staff I will be charged accordingly.

3. I understand that if my animal is undergoing surgery and is found to have fleas that they will be treated
with a flea adulticide at my expense.

4. I hereby also authorize the use of such anesthetics and vaccinations as you deem advisable and the
performance of such surgical and therepeutic procedures as you determine necessary. I understand that
some risks always exist with anesthesia and/or surgery, vaccination, and treatments and that I am
encouraged to discuss any concerns I may have about those risks with the attending veterinarian before
the procedures are initiated. My signature on this form indicates that any questions I have regarding
these issues have been answered to my satisfaction.

5. I agree to indemnify and hold harmless Driving Park at Flint Animal Hospital and the attending
veterinarian from and against all liability arising out of the performance of all procedures referenced herein.

6. I understand that trained personnel will NOT attend hospitalized animals beyond the regular office hours.

7. There is no gaurentee of pregnancy, or a viable litter with any of the following services; Any vaginal AI,
surgical AI, TCI, or caeserians.

Initials (blank line, initial by hand on the printed form): If there is an emergency involving my pet, I consent to additional charges for procedures,
medications, or other nesessary and or lifesaving decisions as the attending veterinarian deems necessary.
I understand by initialing this I am responsible for all charges accrued before, during, and after the emergency,
including potential disposal cost.

Initials (blank line, initial by hand on the printed form): If there is an emergency involving my pet, I decline any additional charges and medications, and
understand that my pet will be labeled as DO NOT RESUSCITATE. I understand that by initialing this I will still
be accountable for all charges that were accrued before the emergency occurred and any potential disposal cost.

PAYMENT OF YOUR BILL IS DUE IN FULL AT THE TIME THE ANIMAL IS TREATED.
I confirm that all of the information on this form is accurate and true to the best of my knowledge.