ACKNOWLEDGEMENT AND AUTHORITY: I, the undersigned, being over 18 years old, agree to pay for
authorized treatment, services and products deemed necessary and/or desirable for the care of my pet(s)
including, but not restricted to medications, conduction of laboratory work, radiographs, performance of
operations and/or other studies that may be utilized by a Doctor of Veterinary Medicine or a qualified CVAH
staff member. I accept full responsibility for the payment of services rendered. I understand that all fees are
to be paid for at the time that services are rendered. I acknowledge that my signature on this form represents
an agreement to comply with the previously stated policies of Country View Animal Hospital. I also authorize
CVAH to inquire and obtain my pets’ previous records from other practices.