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info@southhavenvet.com
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Contact Us
(269) 637-5261
info@southhavenvet.com
Appointment
Home
About Us
Our Team
Testimonials
Photo Gallery
Clinic Tour
Our Services
Resources
Online Forms
Welcome Form
Treatment Authorization Form
Payment Options
Around the Clinic
Contact Us
Treatment Authorization Form
We look forward to seeing you soon! Please use the form below to authorize us to treat your pet.
Get Started
Treatment Authorization Form
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Pets Name
*
Date
Owner’s Name
*
Email
*
Weight
*
Problems / Concerns
*
Symptoms
Has a Temperature/Fever
Lame/Sore
Lethargic
Not Eating
Not Drinking
I authorize these services if deemed necessary:
Bloodwork
Ultra Sound
X-Ray
IV Fluids
Current Medications
Products Needed?
Heartworm Prevention
Flea & Tick Prevention
Diet Refill
Medication Refill
Shampoo/Other
Services Needed Today Too?
Nail Trim
Check/Clean Ears
Fecal/De-wormer
Vaccines
Anal Gland Expression
Vaccines Over-Due/No History of
Canine Distemper
Heartworm Test
Rabies
Kennel Cough (Bordetella)
Lyme
Lepto
Feline Distemper
Feline Distemper Test
Leukemia
Authorization I hereby give permission for the doctor and staff of South Haven Animal Hospital to perform the treatments and procedures I’ve indicated above. I understand that I am responsible for payment of services rendered at the time of the animal’s release.
I need to be called prior to initiation of services.
Initiate any tests and treatments needed today.
Signature of Owner or Agent
*
Clear Signature
Date
*
Comment
Submit
