Please list any medications your pet is currently being administered.

Please indicate the strength and the frequency.

**I, the undersigned, do hereby certify that I am the owner (or authorized agent of the owner) of the above described animal, and I authorize the performance of diagnostic, theraputic, anesthetic, surgical and prevenative procedures or emergency procedures as may be deemed necessary by the veterinarian.

**I understand that payment is due when services are rendered.

**I have read and understand this authorization and consent.

Thank you for allowing us to work with your family member.