Skip To Content

New Patient Information

Client / Owner Information
Pet's Information
One file only.
100 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

I do hereby certify that I am the owner of or possess full authority over the medical decisions concerning all my pets. I understand that there are risks involved in handling animals and their medical treatment, and similar to treating any other living being, there are no guarantees as to the results of any treatment administered. 

I do hereby authorize the veterinarians at University Animal Clinic, as well as their vet-techs and assistants, to examine and/or perform procedures they deem necessary for my pet. Accordingly, I bereby, release, waive and discharge University Animal Clinic and its officers, directors, board members, supervisors, consultants, agents, or employees (collectively referred to herein as “Releasee”) from any and all liabilities, claims demands, or causes of action, whether in contract, tort, or otherwise, including, without limitation, negligence, that may be sustained by me or my pet while my pet is being treated by or under the care of University Animal Clinic (collectively, “Claims”). Additionally, I waive my rights and agree not to initiate any legal action against any Releasee in connection with any of the aforementioned Claims resulting in injury, including death, that may be sustained by me or my pet while my pet is being treated by, or under the care of, or while either my pet or I am on the premises of University Animal Clinic. 

Further, I have informed the University Animal Clinic of any special needs, ailments, illness, or issues that my pet may have, including any proclivity to bite, scratch, claw, jump, or act in an aggressive or potentially harmful manner (collectively, the “Special Needs”), and indemnify and hold harmless the University Animal Clinic of the Special Needs of my pet, and from any injury to any personnel or property of the University Animal Clinic, and/or any person or property on the University Animal Clinic’s premises. 

In the event that any of the exculpatory or indemnification provisions contained in this agreement are deemed unenforceable, or inapplicable to any or all claims, by a court of competent jurisdiction, I acknowledge and agree that the University Animal Clinic’s liability shall be limited to the lesser of one hundred dollars ($100) or the fee paid by me for the services performed on my pet. 

This instrument shall be binding upon the members of my family, my spouse, and my heirs, assigns and personal representatives. This instrument shall be governed by the laws of the State of Florida, and the exclusive venue and jurisdiction for any action brought to interpret or enforce this agreement shall be in the state courts located in Manatee County, Florida. 

I hereby irrevocably waive any and all right to trial by jury in any legal proceeding arising out of or related to this agreement, the services/procedures performed by university animal clinic on my pet, or any liabilities or claims against University Animal Clinic. 

I certify that I have read and fully understand that above waiver and consent form. I certify that I am signing this form freely and voluntarily and that I understand that by signing this form I am giving up substantial rights. I certify that all blanks or statements requiring insertion or completion were filled in before I signed. 

I authorize the attending veterinarian to examine, prescribe for, or treat my pet(s). I assume responsibility for all charges incurred in the care of my pets(s). I also understand that these charges will be paid at the time of release and that a deposit may be required prior to surgery or anticipated major medical care. I also give the attending veterinarian the right to give pertinent information to any outside pharmacy or specialty veterinarian if indicated by University Animal Clinic. I also understand all reasonable precautions and measures will be taken during the treatment of my animals either in the room, in the treatment area, or in surgery. However, there are always risks involved with treating animals, especially during surgery. I understand and accept these risks and give UAC authority to perform assigned and designated treatment of my animal(s) as long as I’m well informed.

Sign above
Back To Top