• Thank you for choosing Pinebrook Animal Hospital. We pride ourselves in offering high quality low-stress medical care and emphasize preventive medicine. We look forward to serving you and caring for your pet’s needs, for many years to come. Please complete this form so we can accurately enter this information into our files and let us know if you have any questions.
  • (We use your email address to send appointment reminders, medical notes, updates, or other relevant information)
  • Number of pets

  • *Please let us know if there are any food allergies within your home! Part of making your pet’s visit special is offering treats-like peanut butter. We would not want to pose a risk to your family if there is a nut allergy present!*
  • PERMISSION TO TREAT PET(S) AND PAYMENT AGREEMENT

  • I certify that I own the above described animal(s) and I do hereby consent and authorize Pinebrook Animal Hospital, Dr. Dubil, her associates and staff, to treat, hospitalize, and administer any vaccinations, medications, tests, surgical procedures, or treatments that the doctors deem necessary for the health, safety and well-being of the animal while it is under their care and supervision. I realize that my pet will be discharged only during regular office hours and the fee, or fees resulting from my pet's care will be paid in full at that time.

    I understand that Pinebrook Animal Hospital (PAH) will use reasonable care toward my animal while it is being treated. However, I acknowledge that there exists a possibility that my animal may become ill or may be injured while at PAH, and that it may injure it's self, refuse food, urinate or defecate on itself, or even die while in the care of PAH. I hereby release and hold harmless PAH (including Dr. Dubil, all veterinarians, staff and employees) from and for all liabilities, claims and/or causes of action in connection with, arising out of, or resulting from PAH's care and treatment of my animal, including but not limited to, claims of negligence, veterinary malpractice, and/or bailment. I understand further that this release of all claims does not apply to claims of willful, wanton, or reckless conduct or claims of gross negligence.

    All arrangements of credit shall be made prior to treatment/surgery. In the event that no prior credit arrangements have been made, all fees shall be paid in full as services are rendered, at the time the animal is discharged. Any fees not paid for within 30 days shall be subject to a monthly service charge of $5 in addition to a finance charge of 1 and 1/2 % per month, (18% annum).

    I agree to assume all interest, attorney's fees and costs of court resulting from default of payment of any charge, incurred for the care of any animal that I bring in on this or any future date and for any legal fees, costs and expenses incurred by PAH to enforce the terms of this contract. In the event that I change my plans, become ill, change my address, or otherwise lose contact with the hospital, it shall be my duty to inform Pinebrook Animal Hospital in writing immediately of such changes.

    I certify that I have read the foregoing, that I understand the provisions thereof, that I agree to abide by such provisions, and that they shall apply to any and all animals that I may bring in on this or any future date.We accept Cash, VISA, MasterCard, American Express, Care Credit and checks as forms of payment.

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