Medical Evaluation

Litchfield Veterinary Hospital

289 Torrington Road
Litchfield, CT 06759


Permission To Evaluate And Treat

I authorize the veterinarians at Litchfield Veterinary Hospital, 289 Torrington Rd., Litchfield, CT.,  to examine, treat and provide medical care to my pet including all diagnostics deemed necessary for a medical evaluation.  A treatment plan will be reviewed with the trainer/ caregiver and the doctors will proceed. 
If my  pet is brought in on an emergency basis and requires immediate intervention, including surgical intervention, the  doctors at Litchfield Veterinary Hospital have permission to treat as deemed necessary for the well being of my  pet.
I understand I will be responsible for all expenses incurred in the treatment of my pet.  Payment arrangements must be made prior to the appointment by contacting our office.

Phone: 860-567-1622

By submitting this form I consent that all information is accurate and give Litchfield Veterinary Hospital, it's doctors and staff, permission to provide medical care, as outlined above, for my pet(s).


Your Name: First/Last
Phone: Primary
Phone: Secondary
Person responsible for pet in my absence:
Contact Information for Responsible Party:
Pet's Name:
Date of Birth:
Male or Female:
Spayed or Neutered:
Microchip #
Additional Comments:
Signature: Please Type Name
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