Star of Texas VH - Admission Consent Form

1
Name* This field is required.
First Name
Last Name
2
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Email* This field is required.
example@example.com
4
Pet's Name* This field is required.
5
I hereby certify that I am the owner of the above-named animal or am responsible for it and have the authority to execute this consent. * This field is required.
YESNO
6
I understand that Star of Texas is NOT staffed 24 hours a day. Hospitalized animals are left unattended during the hours of 6pm to 7am. I understand that I have the option of removing my pet from Star of Texas and transferring my pet to The Animal Emergency Hospital for overnight care if needed. * This field is required.
YESNO
7
Fear Free Visits - If your pet is fearful or stressed while in our hospital, a mild anti-anxiety medication might be given to your pet orally at no additional charge to you. This medication will help decrease fear and anxiety and allows us to better care for your pet. May cause mild sedation. * This field is required.
ACCEPTDECLINE
8
Reason for visit(s)* This field is required.
9
Will your pet have been given any medications the day of their visit?
YESNO
10
If yes, what & when? Please list all medications and the time they will be given
11
Check-off any belongs accompanying your pet to their visit
Leash
Collar
Harness
Food
Medication
Bedding
Carrier
12
We love to show off our patients on social media! I give STVH permission to share my cute pet on their Facebook, Instagram, or TikTok channel.* This field is required.
Yes
No
13
Bloodwork and/or other tests may be necessary for your pet’s diagnosis. If this is needed the doctor should:

Perform whatever procedures are needed     Perform whatever procedures are needed as long as the total bill is under
$
Please call me with an estimate of charges
14
IF YOU CANNOT BE REACHED
Perform whatever is necessary
Only do the exam until I can be reached
15
Signature
Clear
16
Name of person to contact during your pet’s visit* This field is required.
17
Phone number for contact* This field is required.
Please enter your phone
Text
Call
Contact Preference
Should be Empty: