Navarre Animal Hospital

8172 Navarre Pkwy
Navarre, FL 32566

(850)939-1373

www.navarreanimal.com

Hospitalization Authorization

Client Name: (required)

Pet Name: (required)

Date: (required)

I am the owner (or authorized agent for) of the above-mentioned animal.
I have discussed the reasons for the hospitalization and I am satisfied with the plan of management.
The nature of such services has been described to me to my satisfaction and I realize that neither guarantee nor warranty can ethically or professionally be made regarding the results or cure.
I authorize use of sedatives and pain medications if deemed warranted. If anesthesia or sedation is required, I understand, and accept that there are always inherent risks, including death. (Please sign by typing your name): (required)

I have also had the likely fees explained to me and have received the estimate ranging from (please list dollar amount): (required)

I understand the estimate range is for anticipated medical services. It is understood that there may be unforeseen complications and that further treatment may be necessary during the hospitalization.
I accept and assume full and total financial responsibility for any and all services rendered by the clinic, its staff or employees in the treatment of the above described animal and agree to pay the fees at the time of my pet's discharge or other demise. (required)

Please sign this form by typing your name: (required)

Date (mm/dd/yyyy): (required)

Daytime Phone: (required)

Home Phone: (required)


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