Daycare Release Form

Alternate Phone Number:

Color: *

Shiloh Animal Hospital | 1005 Lichtin Blvd, Morrisville, NC, 27560 | Phone: 919.825.1000 | Fax: 919.724.4902 | FrontDesk@ShilohAnimalHospital.com

Address: *

State *

Gender *

Birth Date (or approximate age) *

City *

Co-Owner / Caretaker:

By entering your name below and submitting this form, you are asserting that you have read and agree to all of the above and consent to leave your pet in the care of Shiloh Animal Hospital. *

Name (Pet Owner / Caretaker): *

Primary Phone Number: *

If choosing option #2, please specify dollar amount:

Microchip Number:

Email: *

Daycare Release

Emergency Contact Name and Phone Number: *

Pet's Name: *

Zip Code *

Breed *

If my pet needs treatment for anything OTHER than what is required/what has been requested, I agree to ONE of the following options: *

I authorize Shiloh Animal Hospital to treat my pet as needed and place NO limit on additional charges/services carried out at the doctor's discretion.

I authorize treatment as outlined here and approve charges up to an additional specified dollar amount (specify in the space provided below).

Please call me with a revised estimate before performing any additional procedures not discussed. If I cannot be reached, I authorize additional treatments deemed appropriate by the veterinarian.

I DO NOT authorize any treatment other than what I requested. I understand that if I cannot be reached, my pet will receive NO additional treatments, except in the case of a life-threatening emergency.

*Please note that our hospital will be closed for New Year's Day, Memorial Day, Independence Day, Labor Day, Thanksgiving, and Christmas.

Copyright 2016. Shiloh Animal Hospital. All rights reserved.