General InformationDate MM slash DD slash YYYY Time Hours : Minutes AM PM AM/PM Client Name Pet Name Roseville Animal Hospital where pet is being surrendered Pet and Account InformationColor/Markings: Wellness Plan Status: Payments Remaining: Cancellation Cost: Conditions and Representations of Agreement:I represent and warrant to Roseville Animal Hospital, The pet hospital that I am the sole owner of the Pet listed above, and have the right to transfer, convey and relinquish ownership of the pet to RVAH. For valuable consideration, I hereby transfer all rights of ownership for the Pet listed above to RVAH, the Pet Hospital of I understand that as the new owner of the Pet, RVAH may provide the care and treatment it deems appropriate as its sole discretion. I understand that may include euthanasia as a human treatment option. If possible, RVAH will attempt to facilitate the Pet's adoption to a caring home. At RVAH's option, the Pet may be transferred to a local Humane Society or animal shelter to increase its exposure for adoption. I hereby release RVAH from any and all claims that I have or may have related to the Pet. I understand and agree that RVAH has no obligation to provide further medical treatment to the Pet or to further inform me of the continued health, treatment or placement of the pet. I agree to indemnify and hold harmless RVAH and its employees, agents and staff member from any and all claims of any person claiming an ownership interest in the Pet, including reimbursing RVAH for any costs or express of any kind, including attorney fees it incurs in responding to any such claims. I also acknowledge that I am still responsible for any outstanding financial obligations to RVAH. However, I am under no obligation to any future care or treatment by RVAH to the Pet. I HAVE FULLY READ THIS AGREEMENT, UNDERSTAND ITS TERMS, AND AGREE TO BOUND THEREBY. Client Printed Name Client SignatureDriver's License# Chief of staff/ Hospital Printed Name Chief of Staff/ Hospital Director Signature