Winchester Animal Hospital

901 North Loudoun Street
Winchester, VA 22601

(540)667-0260

www.winchesterpet.com

New Clients, you will need a Client Information, Vaccination Consent, Advance Directive and Staff Hours form filled out prior to your first appointment! 


Advance Directive Form


If there is an unexpected or life-threatening situation involving any of my pets, I would like the following actions taken:

I give permisson for the doctors and support staff of Winchester Animal Hospital to initiate life-saving emergency care and treatment for my pets. I understand that I am financially responsible for these treatments, and I am aware that intial stabilization fees could be up to $500.00.
After the initial stabilization, I will receive an estimate for the rest of my pet’s care... I would like the following pets omited from this directive:

I agree to the above statement (OPTIONAL - 1 of 2 choices) (required)

Yes
No



I do not wish for any heroic care to be performed on any of my pets without my permission and a written estimate. I understand in emergency situations time is of the essence, and by checking this box I will be delaying my pet’s care.
I agree to the above statement (OPTIONAL - 2 of 2 choices) (required)

Yes
No


Client's Name: (required)
First Name (required)
Last Name (required)
E-Mail Address (required) :
County (required)

Client's Phone: (required)
Phone TypePhone Number (required)

In consideration for following my wishes, I hereby release the Winchester Animal Hospital, it’s staff and authorized representatives from any and all liablity that may have subsequently accrued to me, as a result of honoring this directive. I declare that the doctors and staff of the Winchester Animal Hospital are acting in accordance with my wishes. I certify that I am the legal owner or the duly authorized agent for the owner of the pets listed on my record. I understand that my wishes may be carried out immediately upon my signing this agreement. I assume full responsibility for applicable fees as listed above. I fully understand the foregoing provisions. I understand that this advance directive will be honored until I wish to make changes to it.


Any decision I declare on the phone shall supersede my written directives.
I agree that I have read all of the information provided on this form and that all of the above information I have provided is true. (required)

I agree
I disagree


Today's Date: (required) :

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