Longenbaugh Veterinary Hospital 

 

 

 

 

In order to expedite your check-in, you may fill out the form below.  You can print the form and bring it with you or you may submit the form directly from our website. A form submitted directly from our website, will serve as a form with your signature. Only an "owner of record at Longenbaugh Veterinary Hospital of a pet can give authorization for services.  A form submitted directly from the website is a legal contract, for veterinary services and payment for said services, between the pet owner and Longenbaugh Veterinary Hospital.  If an owner wants to allow additional people to have the right to receive medical updates, authorize services, or make payment for services, the owner must submit an agent of owner form. The form gives the agent permission to be listed on our records as an owner or a co-owner in order to authorize and pay for services.  An authorization form signed by and agent of owner is a legal contract. Thank you.  If you have any questions, please call us at 281-856-7023.

 At LVH,we attempt to discuss all aspects of care with you; however, we cannot predict every circumstance or situation which may occur while your pet is hospitalized with us.  We also cannot make any guarantees concerning results, treatments or outcome in regard to your pet's care. There are risks involved with any medical or surgical procedure. Please understand that if further services are required for your pet (even if for the treatment of the same condition) additional expenses will occur, including hospitalization, sedation, medication, diagnostic tests, x-rays, and bandage changes. These additional charges will not be reflected on the original estimate, but will be on the final bill.  If you have any questions regarding the treatment and care of your pet, please do not hesitate to ask.  I understand and agree to the following: I am signing a legal contract for veterinary services and will pay for said services in advance or at the time of discharge, I may ask for an estimate before services are performed, but an estimate is not the final bill, I will pay for any balance due on the final bill at the time of discharge, I need to discuss any financial concerns I have about charges or payment arrangements before services are performed.

(Longenbaugh Veterinary Hospital is not a 24 hour facility.  We do not have patient monitoring during the hours that we are closed.  If your pet requires after hour care, we will

 refer you to the Animal Emergency and Referral Center of West Houston. 

They will discuss their payment policy with you.)

 Please be aware that the law requires us to report all injuries caused from an animal biting a person to Harris County Public Health.  All pets are required by law to

be current on their rabies vaccination.

 

 
                                                                          
 

*Pet's Name
*Owner's Name

We ask that you fill in the name of the owner that is to be contacted about the medical condition of this pet. Please provide a contact number. To avoid confusion, we prefer to have one contact name. The name must be listed on our records as an owner.

You may have some one else drop off your pet, but all forms must be signed by you the owner or co-owner listed on our records.
*Contact Number
*Please explain the reason for your pet's visit.
Is your pet current on vaccinations?
Is your pet on medication?
List all your pet's medications.
I understand that if I need an estimate, I need to ask at the time my pet is dropped off. I also understand that all financial concerns I have or special payment arrangements are to be discussed before services are performed.

As owner I am responsible for all charges at the time of discharge. You may bring this signed form with you to drop off your pet or you may submit it directly from our website. By submitting the form, you are agreeing that you are this pet's owner and th
*Date
Signature for forms not submitted.