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Owner / Caregiver

Please provide the information below as completely as possible. All information is strictly confidential. Complete this form only if you already have an appointment scheduled.

Pet Information

Referral Information

Permission to Treat/Hospital Policy and Release/Telephone Call Policy

By checking below you certify that you are the owner and or agent of the above animal, have the authorization to consent to treatment, and have reviewed the following information. I authorize Animal Dermatology Center and Dr. Alexander Werner to examine, to perform diagnostics, and to treat my companion animal. I understand that Dr. Werner will at no time intentionally endanger the health of my animal. However, I am aware that some medications that may be prescribed may not be FDA-approved for use in companion animals, or for the specific disease being treated. I further understand that the practice of veterinary medicine is not an exact science, and I acknowledge that no guarantees have been made to me as to the results of treatments. I absolve Dr. Werner and his staff of any and all liabilities associated with the examination of my animal, and the diagnosis and treatment of it's disease. I agree that I am responsible for the payment of all charges on my account for these services, and that the fee for all services is due and payable at the time of the office visit or procedure. Outstanding balances are subject to an interest charge of 1.5%. There is a $25.00 returned check fee per incident. Our office policy requires 24-hour notice of all canceled appointments. If a 24-hour cancellation notice is not given to our office, the client will be responsible for the office visit fee. An estimate for fees for all services can be obtained by request. By law, the dispensing of prescription medications requires routine patient examinations. Prescriptions may be refilled without a re-examination only if the patient has been examined during the preceding six months, and if the doctor believes that a refill without re-examination is appropriate and safe for the patient. Dr. Werner is not available for direct telephone consultation with clients unless he determines that it is medically necessary to do so. Clients are encouraged to ask questions about the diagnosis and treatment of their companion animal. However, as a teaching hospital, it is the policy of Animal Dermatology Center that telephone calls will be received, and questions will be answered by the receptionists, veterinary assistants, and/or the senior veterinary students through consultation with Dr. Werner. This policy is strictly adhered to in order to maintain our mission both to provide the highest quality of medical care for our patients and to educate our students; your understanding and cooperation are appreciated.