Wellness Release

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Wellness Release

Owner/ Authorized Agent

Address

City

State

Zip

Phone

Pets Name

Breed

Species

Email

Age

Sex *

M

F

Weight

Spayed/Neutered? *

Yes

No

Color

Do you have a regular Veterinarian? *

Yes

No

If yes, please list

Purpose of Appointment:

Additional Appointment Details

AUTHORIZATION & CONSENT

I request and authorize Wisconsin Community Veterinary Center (WCVC) to vaccinate the above described animals, if indicated as necessary.

I understand that vaccines may cause adverse reactions in some animals, such as a severe allergic reaction or cancer. I hereby release WCVC & it’s employees & volunteers from any claims arising from or connected with any vaccines received today.

I certify that; a.) my animal is current on all recommended vaccines, b.) I am updating overdue vaccines today, or c.) I am waiving the right to protect my animal by choosing to not vaccinate. I understand the inherent risk of failing to maintain current vaccines and waive all claims arising from or connected to this choice.

I certify that my animal is in good health, or I have disclosed all health concerns to the Veterinary staff at WCVC

I understand that WCVC has the right to refuse services to any animal to whom it is deemed a health risk.

I understand that emergency procedures will be attempted if complications arise; these may result in additional charges.

I understand that if my animal is not picked up by the designated check out time, I will be responsible for boarding and overnight care charges. If I do not claim my animal within 5 business days, my animal will become property of the clinic.

I agree to pay for charges incurred today, as well as any aftercare. Unposted charges: In some instances, charges for services rendered may still be in the processing stage when animal is discharged. I agree to pay for charges once a final bill is received.

I hereby release WCVC (SFTS), any employee, or any volunteer from any and all claims arising from the procedures performed today.

By signing below, I verify that I have no questions for the receptionist checking me in.

Date

Thanks for filling out the authorization form in advance.

CONTACT US

4475 Robertson Rd

Madison, WI 53714

Tel: 608-224-1400

reception@wicvc.org

SFTS RESCUE WEBSITE

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