Inpatient Anorexia Form

I, the undersigned, do hereby certify that I am the owner (or duly authorized agent for the owner) of the animal described above, that I do hereby give Animal Hospital of Lake Villa, its agents, and/or representatives, full and complete authority to perform the surgical/medical procedure discussed.
I further consent to the performance of operations and procedures in addition to or different from those now contemplated, arising from presently unforeseen conditions, which the above-named veterinarian or his associates or assistants may consider necessary or advisable in the course of the operation. I further consent to the administration of such anesthetics as may be considered necessary or advisable by the veterinarian responsible for this service. As my signature below indicates, I understand the nature and purpose of the operation, possible alternative methods of treatment, the risks involved, and the possibility of complications, and I have no further questions. I recognize that the practice of medicine and surgery is not an exact science and acknowledge that no guarantees or assurances have been given to me as to the result of any treatment, medication or procedure given at the hospital.
The undersigned also understands that all services are to be paid in total when the pet(s) is/are discharged unless prior arrangements are made. The owner or agent promises to pay such total, together with any other charges, finance and/or collection, due thereon. A written estimate will be furnished upon request. Forms of payment accepted include Cash, Mastercard, Visa, American Express, Discover, Scratchpay, or Care Credit. Personal checks are not accepted as a form of payment.

Animal Hospital of Lake Villa
101 S. Milwaukee Ave.
Lake Villa, IL 60046

Phone: (847) 356-8387
Text: (847) 356-8387
Fax: (847) 558-2606

Premier Veterinary Group
Emergency: (847) 548-5300

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