*$25 OFF FOR NEW CLIENTS – LIMITED TIME ONLY!
*Mention this discount at checkout to redeem. Valid for new clients’ first visit at Litchfield Veterinary Hospital only. Limit one per household. Not redeemable for cash.

Medical Evaluation Form

Share important details about your pet’s health before your visit. This form helps our team prepare thoughtful, personalized care.

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Share Your Pet’s Health Details for Better, Faster Care

Permission To Evaluate And Treat

I authorize the veterinarians at Litchfield Veterinary Hospital, 289 Torrington Road, 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 owner/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: 860-393-0593
Email: LVH@litchfieldvet.com

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

Microchip Pet Secondary

Client Information

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

Secondary Phone

E-mail *

Person Responsible For Pet in My Absence *

First

Last

Responsible Party Phone *

Patient Information

Pet's Name *

Date of Birth *

Breed *

Sex *

Male
Neutered Male
Female
Spayed Female

Microchip #

Additional Comments:

Signature *

Clear Signature

Today's Date *

Name

Medical Evaluation Form

Share Your Pet’s Health Details for Better, Faster Care

Permission To Evaluate And Treat

Client Information

Patient Information

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