Patient Name First Last Date MM slash DD slash YYYY Client Name First Last Primary Reason for Visit Please Read and Initial BelowI do hereby give Mountain View and it’s employees permission to perform the procedures and treatments deemed necessary for my pet listed above. I have been informed and understand the benefits and complications of these procedures and treatments.I understand that Mountain View is Not a 24hr emergency facility and will not see or keep animals after hours. I understand that in an emergency and/or if my animal needs continued care I will need to transport my animal at my own cost and resources to the nearest after hours emergency animal hospital. (Veterinary Emergency Services of Verona Animal Hospital 540-248-1051).I understand that any costs discussed are estimates and costs may vary. I also understand that I am responsible for any additional costs that occur.I understand that payment is due in full at the time of service. Any checks returned for insufficient funds are subject to a $35 returned check fee. Any accounts left unpaid after 90 days are subject to legal collection activities.SignatureDate MM slash DD slash YYYY
