**To aid in preventing the spread of infectious diseases, all patients staying in our hospital must be current on ALL vaccinations and free of internal and external parasites. If your pet has internal or external parasites, it will be treated at the owner's expense.

I hereby authorize the veterinarian to examine, prescribe for, or treat the described pet(s). I assume responsibility for all charges incurred in the care of this animal. I understand that these charges must be paid at the time of services rendered and a deposit may be required for surgical or hospitalization treatments. We accept all major credit cards, cash, and Care Credit.

By entering my name, I acknowledge that I have read Gully Animal Hospital Midlothian's Authorization form and agree to adhere to their policies and procedures.