By completing the form I agree that I assume full financial responsibility for the above described animal and I do hereby authorize Crossroads Veterinary Hospital to hospitalize and treat this animal as the doctors deem necessary for the health, safety or well-being of the above animal while it is under their care and supervision.

PLEASE NOTE: There may be additional charges associated with your pet's surgery

1. If your pet has an undescended testicle (cryptorchidism), there will be an extra fee of $25 if the testicle is extra-abdominal or $75 if intra-abdominal
2. If your pet is not current on "Core" vaccines, they will be provided at additional cost of $26
3. If fleas found on patient, flea treatment will be provided at an additional cost of $8
4. If your dog has an unknown heartworm status, he will be tested before anesthesia at an additional cost of $29
   • Current if tested negative in the previous 4 months
   • Current if tested in past year and proof of heartworm prevention can be provided

Optional Recommendations

Pre-op Bloodwork: We offer and strongly recommend pre-anesthetic bloodwork for all pets undergoing surgery.

By completing this form I agree that if anything detrimental should accidentally occur to this animal while in the hospital, I will hold Crossroads Veterinary Hospital free of any responsibility and/or liability in the absence of gross negligence. I understand that payment in full is due at the time the animal is discharged. 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, I agree that Crossroads Veterinary Hospital may assume that the pet is abandoned and are authorized to dispose of it as they see fit. I agree that abandonment of this animal does not release me of my obligation for the bill. I further agree that in the case of non-payment, a finance charge of 1.5% per month (18% per annum) will be charged and that any collection fees or attorney fees will be paid by me.