Extra Links – Shannondale Pet Hospital

Please have one primary owner/decision maker fill out and sign this section. Additional people who are authorized to make medical decisions can be listed in the following section as Designated Caregiver. .

Name*

First Last

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Preferred Phone Number*

Alternate Phone Number

Terms and Conditions of Service

This agreement is between the person listed above as the primary owner (hereafter "Client") and Dr. Teresa Wasilewicz, owner of Shannondale Pet Hospital (hereafter "Vet")*

I understand and agree

Veterinary-Client-Patient-Relationship (hereafter "VCPR"): this is required for the Vet to be able to give medical advice, prescriptions, recommendations, prognoses, or treatments*

I understand and agree

VCPR Establishment: this agreement does not establish a valid VCPR. A VPCR will not be established until the Vet has examined the patient and agreed to provide veterinary services*

I understand and agree

VCPR Duration: Due to the continued demand for our veterinary services and our commitment to delivering comprehensive health care, we will only be able to extend veterinary services such as but not limited to medical advice, prescriptions, treatments, recommendations and urgent and emergency services to patients who have been seen for a wellness exam within the last year. It is important that we maintain a current veterinary-client-patient relationship which includes annual wellness care for healthy patients and regular progress assessments for those with on-going health concerns. Wellness health care is cornerstone to our practice, and pets receive numerous benefits from wellness visits including fewer illnesses, improved quality of life and longevity.

I understand and agree

VCPR Termination: this relationship may be terminated by the Client at any time. If the Vet terminates the relationship, alternative options for care will be provided. Termination of the VCPR does not affect the Fee or Payment Agreements and all payments will still be due.*

I understand and agree

Outcomes, Prognoses, Diagnoses: All procedures and treatments carry inherent risks, including the possibility of death. Despite good faith efforts, a successful outcome cannot be guaranteed following any treatment. Prognoses and diagnoses will be based on all available evidence and made in good faith, but their accuracy cannot be assured*

I understand and agree

Here at Shannondale Pet hospital, we prioritize a compassionate and professional environment for both pets and their owners. We encourage clients to maintain respectful and courteous behavior during visits, as this fosters a positive atmosphere for all. Open communication is key—feel free to ask questions or express concerns about your pet’s care. Together, we can create a supportive space and high quality care for your beloved companions.*

I understand and agree

Limited Services: The Vet offers veterinary services during the posted hours of operation from Monday to Friday only and is not available on an urgent or emergency basis after hours. If the Vet is not available, care can be found by calling our emergency triage service called Smart Vet at 705-410-2041* If in hospital care is warranted, the Smart Vet service will contact the local veterinarian on duty for care.*

I understand and agree

Payment Agreement: Payment is due in full at time of service. The Client agrees to render payment in full when due. The Vet will accept payment in the form of cash, credit card, debit card, or e-transfer.*

I understand and agree

By signing below I attest that I understand and agree to all the above terms and conditions*

First Name Last Name

Is anyone else authorized to make medical decisions for your pet(s)? This would typically be a spouse/partner, relative, or close friend*

Yes
No

If "Yes" to the above question, please specify

Name of designated caregiver

First Last

Email of designated caregiver

Phone Number of designated caregiver

Name and contact information of any additional caregiver(s)

I authorize the above named person or people to make medical decisions for my animal(s)

First Name Last Name

Please have one primary owner/decision maker fill out and sign this section. Additional people who are authorized to make medical decisions can be listed in the following section as Designated Caregiver. .

Terms and Conditions of Service

Download Our App