Drop off / Hospitalization Authorization Form

Date *

Date

Client Name *

First Name Last Name

Patient Name *

If your pet is being seen by a doctor today, after doctor’s exam may we perform the following: *

Yes, please proceed with whatever testing and treatment is recommended outside of the treatment plan/estimate. No, I prefer to be contacted before any additional testing or treatment is performed outside of the treatment plan/estimate.

In case of Hospitalization, we do not have personnel here after hours. When the clinic closes at 6:00 pm, no one is here to monitor hospitalized patients. If your veterinarian is concerned about this, they will recommend you transfer you pet to an emergency hospital for overnight care. *

I have read and understand the above statement and have elected to keep my pet at North Austin Animal Hospital for the duration of required hospitalization. I have read and understand the above statement and will transfer my pet to an Emergency Clinic upon discharge from North Austin Animal Hospital. I have read and understand the above statement. I would prefer to make my decision on a case-by-case basis with the doctor.

*** We operate a flea free facility and in order to maintain this standard, flea treatments are required for boarding/drop-offs. A charge will be assessed for Capstar administration. ***

I understand that I will be asked for a deposit of up to 50% of treatment plan/estimate at patient drop off. I also understand that payment is due at the time services are rendered and when my pet is released from the hospital. I know that I will be responsible for the entire amount of my pet’s treatment and agree to pay this amount in full upon discharge.

Phone Number *

Best number for contact during patients stay

Signature *

Clear

Drop Off / Hospitalization Authorization Form