Owner Name* Co-Owner Name Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Address Home Number Work Number Cell Number* Co-Owner Work Number Co-Owner Cell Number Name of Previous Clinic Phone Military Yes No Senior Yes No Recommended by Whom? Place of Employment First PetSelect One:* Dog Cat Pet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredDate of VaccinationsRabiesDA2PParvoCoronaBordatella Date of VaccinationsRabiesFELVENT-FVRCPFIP Second PetSelect One: Dog Cat Pet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredDate of VaccinationsRabiesDA2PParvoCoronaBordatella Date of VaccinationsRabiesFELVENT-FVRCPFIP Third PetSelect One: Dog Cat Pet InformationNameBreedMicrochip#Date of BirthColorSexSpayed or NeuteredDate of VaccinationsRabiesDA2PParvoCoronaBordatella Date of VaccinationsRabiesFELVENT-FVRCPFIP I/we hereby authorize the veterinarians to examine, prescribe for, or treat my pets (s). I/we assume full responsibility for all charges incurred in the care of this/these animal(s). I/we also understand that these charges will be paid in full at the time of release and that a deposit may be required for certain surgical treatments or other procedures.Critical Care Authorization - Your pet has been presented to AV Veterinary Center with a critical or life threatening condition. We require authorization to initiate and or continue critical care in an attempt to stabilize your pet. This initial stabilization may include an IV (intravenous catheter and fluids, emergency bloodwork, X-rays and possible CPR). We estimate the initial cost of stabilization to be $600 - $850 The veterinarian on duty will speak to you a soon as possible. At that time they will provide you with an initial prognosis and estimate of costs for continued diagnostics and care. I authorize AV Veterinary Center to continue emergency treatment of my pet and understand critical care deposit is required in advance.* Yes No Medical CPR: I authorize obtaining an airway, breathing for my pet, external chest compressions and the administration of drugs and fluids in an attempt to re-establish circulation and respiration, if needed. I understand that charges may be incurred.* Yes No Type Signature NameThis field is for validation purposes and should be left unchanged.