Anesthesia Release Form

  • Client Information

  • Patient Information

  • MM slash DD slash YYYY
  • Referring Veterinarian Information

  • Employment Information and I.D.

  • We thank you for allowing us the opportunity to care for your pet. In order to provide the best possible animal medical care, we require that all professional fees are due at the time services are rendered. For your convenience Curbside Veterinary Clinic accepts several forms of payment including cash, personal and business checks, as well as credit cards (VISA, Mastercard, Discover, and American Express). A $40.00 service charge will be incurred for any returned check. For information on Care Credit, a healthcare financing plan, please inquire with our staff. To expedite your check out process during any house call visit, please inquire about our Express Pay Credit Service. By signing below, you acknowledge that you are responsible for making medical decisions on behalf of your pets and accept financial responsibility for their care.