New Patient Form – One Per Pet


Sign / LocationApplewood Pet ResortInternet (Tell us where below)Other (Describe below)Personal Referral (Tell Us Who We Can Thank Below)


Yes, my pet was born to be a STAR!No, my pet is shy

Patient Information


yesno


Financial, Medical information and Liability Release
I understand every effort will be made to achieve a successful outcome and to provide for all possible safety issues in hospital care and handling. I hereby authorize Applewood Animal Hospital to receive, prescribe for, treat and/or perform surgery upon the pet(s) listed herein and additional pets I present. I understand that no guarantees have been made as to the results of medical and/or surgical treatment. I agree to release Applewood Animal Hospital and its staff from any liability resulting from the treatment, surgery and/or hospitalization of my animal(s). I certify that I am over 18 years of age and am the owner or owner’s authorized agent of animals identified on the Patient Information Form. I agree to pay fees for services rendered at the time the pet is discharged from the hospital or as agreed prior to treatment. I assume full responsibility for all charges incurred in the treatment of my pets. I agree that in the event that any unpaid balance is referred to a collection agency, I will be responsible for all collection fees, legal fees and court costs and my owed balance may substantially increase.

I Agree