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Consent for Admission Form

"*" indicates required fields

Client First Name*

Client Last Name*

Pet's Name*

Procedures to be performed*

I, the undersigned owner or agent of the owner of the pet identified above, certify that I am over the age of 18 and authorize the veterinarian(s) at this practice to perform the above procedure(s).*

Yes

I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. My signature on this form indicates that any questions I have regarding the following issues have been answered to my satisfaction:

The reasonable medical and/or surgical treatment options for my pet
Sufficient details of the procedures to understand what will be performed
How fully my pet will recover and how long it will take
The most common and serious complications
The length and type of follow-up care and home restraint required
The estimate of the fees for all services
Any necessary payment arrangements

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand and accept that veterinary medicine is not an exact science and that no guarantee or warranty has been made regarding the results that may be achieved. I agree to pay a deposit of 50% of the estimated fees, assume financial responsibility for the remaining fees, and provide payment via cash, credit card, or check at the time my pet is discharged from the hospital.

Should unexpected life-saving emergency care be required, to quickly and effectively carry out your wishes in an emergency situation, we ask that you choose whether or not you wouild like our team to start resuscitation efforts (CPR) for your pet in the event of a cardiac or respiratory arrest.

Would you like our team to start CPR in the event of cardiac or respiratory arrest?*

Do Not Resuscitate

Resuscitate, CPR (Basic life support including stabilization) $150 – $300

*Wearing an E-collar is important to be adhered to at all times during recovery. In the event that your pet does remove his/her sutures as a result of not wearing the E-collar, you will be responsible for any costs incurred to sedate, treat, replace sutures, and/or medication deemed necessary by our doctors.

I understand that veterinary care during nighttim hours and/or weekends is provided at the discretion of the attending veterinarian. Continuous presence of personnel may not be provided during these hours.

If I desire that my pet have supervision when this facility is closed*

I elect to pick up my pet and provide such care in my home, in which case I accept all risks of adverse side effects

I elect to have him/her transferred to a local emergency clinic where overnight veterinary supervision is available at my expense

I have read and understand the nature of the above procedures and instructions and give my consent to proceed.

Phone number for today's visit*

Alternative phone number for today's visit

Signature of Owner or Authorized Agent*

Date*

Comments

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