Consent to Treatment

Owner's Name*

First NameLast Name

Best contact number for questions during time of admission:*

Area CodePhone Number

Pet's Name*

Pet's Age:

Pet's Species*

Breed & Color (Specify species if "other" is selected)*

Please confirm what your pet is being treated for (Ex. Hospitalization, Surgical Procedure, etc.):*

I, the undersigned owner, agent of the owner, or Good Samaritan responsible for seeking veterinary care for the pet hereby consent and authorize the Doctors at Berkeley Dog and Cat Hospital to prescribe medication for, treat, hospitalize, sedate, anesthetize and/or perform surgery on my pet.

If a procedure is planned, I authorize the use of sedation and/or anesthesia and other medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure(s) as directed by the veterinarian. I have been advised as to the nature of this procedure to be performed and the risks involved. I understand also that there is always a risk associated with any sedation or anesthesia episode, even in apparently healthy animals, and have discussed my concerns with the veterinarian. 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 judgement. I accept responsibility for any result in additional charges.

I understand that no guarantee can be made as to the outcome of treatment and that I am encouraged to discuss any concerns I have about the risks of treatment with the attending Veterinarian before any procedures or treatment is initiated.

I confirm that I have received a treatment plan including an estimate of the costs for veterinary services and that I am encouraged to discuss all fees related to such care before services are rendered and during my pet's ongoing medical treatment. I understand that the estimate I have just received is only an ESTIMATE of charges for procedures discussed and agreed to during my pet's examination.

I assume responsibility for all charges and services incurred for my pet and agree to pay such charges at the time of release.

I agree to pay a deposit of 100% of the low end of estimate fees and agree to pay the remaining fees, and provide payment via cash or credit card at the time my pet is discharged from the hospital.

Please confirm:*

Yes, I have read and understand the above statement and agree to the treatment plan and estimate I received. I give Berkeley Dog & Cat Hospital consent to treat my pet. If my pet's treatment plan includes general anesthesia or sedation, I acknowledge that some side effects of anesthesia may include mild nausea, prolonged recovery, or, in very rare cases, death. I have been advised of the nature of the procedures and of the potential risks.No, I do not give Berkeley Dog & Cat Hospital consent to treat my pet.

Please tell us if you have any special requests:

While your pet is admitted to the hospital, our staff will make every effort to prevent complications arising from your pet’s illness/injury or from planned sedation or surgical procedures under anesthesia.

While hospitalized, if your pet suffers respiratory arrest (stops breathing) or cardiac arrest (the heart stops), we need to know your wishes concerning treatment.

All patients admitted to Berkeley Dog & Cat Hospital must have a resuscitation directive regardless of severity of illness.

Please choose one of the following options for your pet in the case that they may go into cardiac/respiratory arrest:*

CPR: I wish the staff of Berkeley Dog and Cat Hospital to perform CPR (Cardio Pulmonary Resuscitation) on my pet if my pet suffers respiratory or cardiac arrest with no guarantee of survival. The estimate for initial CPR is $300 to $500.DNR, and authorization of humane euthanasia: - If my pet suffers respiratory or cardiac arrest, DO NOT perform CPR. Please provide any additonal drugs needed to help my pet pass with ease.DNR - Do Not Resuscitate: I DO NOT want CPR performed on my pet. I understand that if my pet undergoes respiratory or cardiac arrest, they will eventually pass, but death may not be instantaneous. Do not administer any additional drugs to facilitate their passing.

I am the owner or agent for the owner and have the authority to execute this consent. I have read and understand the agreement.*

Berkeley Dog & Cat Hospital

Consent to Treatment

Hospitalization Code Status