Montgomery Animal Hospital
827 Bethlehem Pike
Flourtown, PA 19031
(215) 233-3958
MM slash DD slash YYYY
I am either the owner or responsible representative of the owner and have the authority to give this consent. By signing, I am agreeing that my pet have an ultrasound performed. I agree to indemnify and hold Montgomery Animal Hospital and its employees harmless from and against any and all liability arising out of the performance of any of the procedures referred here.

If my pet should injure itself in an escape attempt, refuse to eat, soil itself, become ill or die while in the hospital, I agree not to hold Montgomery Animal Hospital and/or its staff responsible and/or liable in the absence of gross negligence. If repairs for such activities are required, I agree to pay for all costs needed to repair any self-inflicted damage.

I further agree that I am responsible to pay in full for the listed procedures/treatments at the time my pet is discharged. If I fail to pick up my pet within five (5) days of receiving written notice mailed to my address on record, Montgomery Animal Hospital may consider my pet to have been "abandoned" by me. In this case, ownership of the pet will be relinquished and handled at Montgomery Animal Hospital's discretion. I understand that "abandonment" does not release me from my obligation to pay my pet's bill including any extra costs incurred due to my "abandonment."

I further agree that in the case of non payment of my pet's bill, a finance charge of 1-1/2% per month (18% per annum) will be charged on the unpaid balance, and that the finance charge and any collection fees incurred by Montgomery Animal Hospital will be paid by me.
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