Name: Birmingham Animal Hospital + Resort
Address: 2316 1st Ave South, 35233
Telephone: +1-205.406.6710
Price range: $$

Pet Name*
Client Name*
First Last
Phone*
Email*
Emergency Contact
Phone
Exam-Comprehensive
- Price: $65.00
- QTY: 1
Pro Pectalin Tabs
- Price: $25.33
- QTY: 14
FortiFlora SA Canine
- Price: $35.00
- QTY: 1 box
Canine i/d Low Fat Rice, Veg, and Chicken Stew Can
- Price: $$22.16
- QTY: 4 cans
Exam - Comprehensive: $65.00 (1)

Purpose: To check on the overall condition of the patient and identify any underlying issues.
Pro Pectalin Tabs: $25.33 (14)

Purpose: To treat loose stool and aid in stabilizing the digestive system.
FortiFlora SA Canine: $35.00 (1 box)

Purpose: A probiotic to help relax and support the gastrointestinal system.
Canine i/d Low Fat Rice, Veg, and Chicken Stew Can: $22.16 (4 cans)

Purpose: Sensitive stomach food to support the dog's digestive health over the next few days.

Total Cost: $155.74
Authorization for Treatment:

I authorize Birmingham Animal Hospital + Resort to initiate treatment for my dog, for stress-related diarrhea and inappetence as described in the treatment package above. I understand that the total cost for this treatment is $155.74. I acknowledge that while Birmingham Animal Hospital + Resort will make every effort to contact me concerning my dog's condition, this authorization allows them to begin necessary treatment immediately to ensure the well-being of my dog while waiting for my response.
Owner's Signature:*
Date*
MM slash DD slash YYYY
By signing this form, I agree to the treatment plan and the associated costs and understand the steps taken to address my dog's condition promptly and effectively.
Comments
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