I, the undersigned, do hereby certified that I am
the owner or dull authorized agent for the owner
of animal described as above. I do hereby consent
and authorize the Gateway Animal Hospital and its
staff to obtain medical record from previous Animal
Hospital Veterinarian if necessary. I do hereby
authorize the veterinarian to examine, test, treat
& prescribe for the pet as above. I assume full
financial responsibility for all the charges incurred
in the care for this pet. I also agree to pay all
such charges when service (s) or treatment is rendered.
Pet Owner or Authorized Agent : Date:........................
fill it on line, print it and bring it with.
We accept payment viaCash, Check, American Express, Discover,
Master & Visa Card.
In order to provide you with high quality services, we request
that payment be made at the time of services rendered.