Hospitalization Consent Form

Hospitalization Consent Form

Lifetime Pet Centers of New Richmond & Williamsburg
Please select at which hospital your pet will be receiving treatment:*

New Richmond
Owner's Name*

First NameLast Name
Primary Contact Number*

Area CodePhone Number
Secondary Contact Number

Area CodePhone Number
Email
example@example.com
How would you prefer to receive updates while your pet is hospitalized with us?*

Phone CallText MessageEmailAny of the aboveOther
I hereby consent and authorize Lifetime Pet Center to prescribe for, treat, or operate upon:
Patient Name*
Age*
Years
Species*

CanineFeline
Breed*
Description*
Coat color, coat length, markings, etc.
Sex*

Intact MaleNeutered MaleIntact FemaleSpayed Female
Please list your pet's current medications, diets, & supplements:*
Include drug/ supplement name, dosages, frequency of administration, last time the medication/ supplement was given, diet brand/name, dry/wet/both, life stage, & amount fed at each meal, meal frequency, etc.
Does your pet have any known allergies or drug sensitivities?*

YesNoOther
If your pet has allergies or drug sensitivities, please list them below:
When was the last day your pet ate?*

MonthDayYear
Date
When was the last time your pet ate on the date above?*

:HourMinutesAM/PM Option
I have been advised to the risks associated with treatments and/or surgery. It is thoroughly understood that I assume all risks and will take responsibility for payment of services rendered.

Lifetime Pet Centers will use all reasonable precautions against injury, theft, escape, or destruction of the animal listed above, but will not be held responsible in any many whatsoever on account of the care, treatment, or safekeeping of the animal described above, as long as acceptable procedures of veterinary medicine have been followed.

It is also noted that my pet will be vaccinated if medically neccessary or if recommended by the prescribing doctor in order to protect the safety of my pet and the staff handling my pet. In addition, if my pet is found to have fleas, ticks, or other parasites, internal or external, while in the hospital, s/he will be treated accordingly as seen fit by the doctor and staff. Please notify us if your pet has any allergies or drug sensitivities.

After reading the above, I have signed to acknowledge recepit and understanding:
Signature*

Clear
Date*

MonthDayYear
Date
Procedure being admitted for: Hospitalization

Your pet is being admitted for hospitalization. We may discover additional conditions or complications while your pet is here, which can incur additional charges.
Please indicate how you would like us to handle these situations should they occur:*

Do the procedure, treatment, and/or diagnostics regardless of cost.Call with an estimate for additional charges. If we are unable to reach you we may do the procedure, treatment, and/or diagnostics.Call with an estimate for additional charges. If we are unable to reach you DO NOT do the procedure, treatment, and/or diagnostic.Authorize a certain amount for charges, we will call you if those charges are exceeded.Other
By signing below, you acknowledge the estimate provided to you for hospitalization and associated costs is not a guaranteed price for services. There are often unforseen circumstances that could result in an increased cost for the care of your pet. We will make a reasonable effort to inform you and gain consent for additional services before proceeding.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: