Thank you for giving us the opportunity to care for your pet. We’ll be happy to answer any questions you have about your pet’s health. To ensure the best care possible, please take the time to fill in this form completely. Thank you!
We respect your privacy and will not share your personal information with others unless authorized.
Pet Health History
I hereby authorize the veterinarian to examine, prescribe for or treat the above described pet(s). I am eighteen(18) years or older and I am responsible for all charges incurred in the care of this pet(s). I also understand that these charges will be paid for at the time of service and that a deposit may be required for hospitalized or surgical patients.
There will be a 1.24% interest service charge added to all accounts over sixty(60) days. The monthly minimum fee will be $1.00 to cover billing and postage. All collection fees if applicable will be added to the account balance.
In the event that I, as the owner of the pet(s) described above, am unable to bring my animal(s) in for a veterinary procedure, routine appointment, surgery, emergency situation, I give my consent to the person(s) listed below to act as an authorized agent in my absence.
I understand in some situations this person may be a minor. I understand that in situations in which a minor comes in with the animal(s) for an appointment, only services pre-authorized by myself as the owner will be performed. If other services, vaccinations for example, need to be performed when the minor comes in, I will be available via phone contact. If I am not available via phone contact, or unable to come to the phone, I understand that additional services will not be performed and I will have to reschedule an appointment or pick up medications at another time.
I also understand that it will be by responsibility to send payment with the individual listed below or have advanced payment arrangements made with our business manager.
If situations arise in which medical or financial information is requested by an individual other than myself or an above authorized agent, I understand that employees of Kronenwetter Veterinary Care cannot release this information without written consent by myself or an authorized agent. I understand that the only information that can be released would be medical information regarding specific situations at an appropriate government or public health official’s request, for example, rabies vaccination status.
In situations in which an individual listed above is no longer an authorized agent, it will be my responsibility to inform Kronenwetter Veterinary Care of this change in writing.
In emergent situations, if I or an authorized agent listed above are not available, I understand that agents at Kronenwetter Veterinary Care will provide treatment to stabilize my pet(s) until contact can be made with myself or an authorized agent. In the event that end of life issues arise, I give my full authority to the veterinarians at Kronenwetter Veterinary Care to make the best possible decision for my pet(s). I understand that I will be financially responsible for the care provided and will not hold any agent at Kronenwetter Veterinary Care responsible for any treatment choices.