A Splash of Color Daness

Hospitalization and Surgical Release Form


Owner's Name: _______________________________	Date: ___________________________
Address: ____________________________________	Phone Day: ______________ Cell: _________________
City & State: _________________________________	Sex of Animal: _______ Breed: ___________________
Animal's Name: _______________________________	Color: ________________________________________
Date of Birth: _________________________________	Weight: _________________

I certify that I own the above described animal and authorize Kay Roush, Ted Roush, Dr. Lee Panko of Fayette Co. Veterinary Clinic, Inc. and/or it's staff to hospitalize said animal for the purpose/procedure of Ear Cropping. During this time they may administer vaccinations, medications, tests, surgical procedures, anesthetics, or treatments they deem necessary for the health, safety, and well-being of said animal while under their care and supervision.

If said animal should injure itself in an escape attempt, refuse food, soil itself, become ill, or die while in the hospital, I will hold Fayette Co. Veterinary Clinic, Inc. and staff free of all responsibility and/or liability in the absence of gross negligence.

I further realize that I am responsible for payment of ALL above mentioned procedures and treatments in full at the time the animal is discharged and any future expenses and NOT Kay Roush, Ted Roush, ASOCD or A Splash Of Color Danes.

If I neglect to pick up the animal within five (5) days of written notice that it is ready for release and mailed to the above address, you may assume that the animal has been abandoned and you are to give it, at no charge, only to Kay or Ted Roush to do with as she/he wishes. Abandonment, however, does NOT release me of my obligation for payment of said bill.

Owner: _______________________________________ Date: _____________________________________