Providence Veterinary Hospital

2400 Providence Avenue

Chester, PA 19013  

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Owner:      

Case No:   

Street:       

City:             

Phone:       

Patient:      

Breed:      

Sex:              

Age:            

Color:       

Markings:________________________________________________________________

I, the undersigned, do hereby certify that I am the owner (duly authorized agent for the owner) of the animal described above, that I do hereby give Dr. Herman, his agents, servants, and/or representatives full and complete authority to perform the surgical procedure described as:

_____________________________________________________________________

_____________________________________________________________________

and to perform any other procedure including sedation and or anesthesia, at his discretion, may be useful to promote the health of the above described pet, and I do hereby and by the presents forever release the said doctor, his agents, servants, or representatives from any and all liability arising from said surgery on said animal.

 I have read and signed the Safety and Comfort Form, which is part of this agreement.

My pet  has had no food past 6 pm and no water since midnight.

Signed ______________________________________________________________

Date:

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Providence Veterinary Hospital l 2400 Providence Avenue  l Chester, PA 19013  l 610 872 4000

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