New Client and Patient Form

Please provide the information below as completely as possible. All information is strictly confidential.

 PROFESSIONAL FEES ARE TO BE PAID AT THE TIME SERVICES ARE RENDERED  You certify that you are the owner or duly authorized agent of the owner and are over eighteen years old. You hereby authorize the veterinarians at Rose City Veterinary Hospital, their agents, employees, and representatives to: examine, diagnose, prescribe medications (recognizing the some medications use may be off-label), perform therapeutic procedures and/or surgery that their judgement may dictate to be advisable for the well-being of the patient. By signing below you understand that the veterinarian or support staff is unable to guarantee the outcome for the treatment or care provided. You expressly agree to release Rose City Veterinary Hospital., it's agents and its representatives, from liability for any/all damages to my pet and to hold Rose City Veterinary Hospital., its agents and representatives harmless from any and all liability (except in the case of gross negligence) associated with the treatment and services performed on your pet. Payment is due when services are rendered. In the event of special circumstances payments arrangements must be discussed PRIOR to treatment. Should your pet be discharged with an unpaid balance there will be a finance charge of 1.5% monthly (18%APR) on any unpaid balance. Should it be necessary to send your past-due delinquent account to our collection agency or small claims you will be financially responsible for all fees incurred.   By signing below you agree that you understand the terms and conditions mentioned above.