Patient Admission and Consent Form

Owner's Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Cell Phone Number*

Area CodePhone Number

Email*

example@example.com

Pet's name*

Breed*

Sex*

Age*

Weight*

Type of Procedure*

spay/neuter/dental, etc.

Has your pet had any food or water since midnight last night?*

YesNo

Current diet*

Type of food

Has your pet been coughing, wheezing, or breathing hard?*

YesNo

Has your pet been vomiting or having diarrhea?*

YesNo

Do you want your pet microchipped for additional fee?*

YesNo

Does your pet have any allergies?*

YesNo

Allergies yes - please explain

Has your pet ever had an adverse reaction to any medications?*

YesNo

If yes, explain:

Is your pet taking any medications?*

YesNo

List medications, dosage, and last given:

Please note:

A topical treatment will be applied at the owner's expense to any pet with evidence of fleas, flea dirt, or ticks.
An Elizabethan Collar may be required for your pet's comfort and protection; prices vary according to size.
For the comfort of your pet, pain management is given for all surgical procedures.

Authorization

I verify that I am the owner (or authorized agent for the owner) of the above named pet and authorize the above procedure to be performed by College Garden Animal Hospital. I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure as directed by the veterinarian.

I have been advised as to the nature of this procedure to be performed and the risks involved. No guarantees have been made regarding the outcome or cure. I understand that there is always a risk associated with any anesthesia episode, even in apparently healthy animals, and have discussed my concerns with the veterinarian. The veterinarian has provided me the opportunity to ask questions and receive answers regarding the procedure. This risk includes serious bodily injury or death. I understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated for the safety or care of my pet. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian’s professional judgment. I accept responsibility for any result in additional charges.

I agree to be responsible for all charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital. I understand no staff will be attending to my pet overnight. All pets who undergo sedation will be kept overnight for observation. Closed system cameras may be used to monitor overnight pets. Staff perform evening checks on hospitalized patients.

In the event of an unforeseen emergency, we will attempt to reach you without delay. Please know that we will take every precaution to ensure that your pet is safe and healthy enough to undergo their procedure today. Any known risks will be discussed with you. However, very rarely, emergencies do happen and we want to know your preference if no one can be reached.

Please check your preference:

In the event an emergency arises and we are unable to reach you immediately, do you want us to proceed with life saving measures, or not proceed with life saving measures (costs incurred):*

Please PROCEED with extreme life-saving measures. I accept responsibility for all costs incurred. Additional life saving charges can include: CPR starts at $59 and can go up to $250 depending on fluids/medications required.Please DO NOT PROCEED with extreme life-saving measures. I accept responsibility for all costs incurred.

I have read and understand the information printed above.

Signature*

Date*

Date

Phone Number to reach you at today*

Area CodePhone Number

Alternate Phone Number

Area CodePhone Number

Anesthesia Release Form