Day-Admit Consent Form
Best phone number to contact you
Alternate phone number
Date of Appointment
Scheduled Appointment Time
To find you when coming to get your pet out of your car in the parking lot.
Procedure(s) to be performed/ Reason for visit. If any concerns, please state how long the concern has been going on.
I am the owner or agent of the designated pet and have the authority to execute consent. I understand that during the performance of the foregoing procedure(s) unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure(s) or different procedure(s) than those set forth above. I have been advised to the nature of the procedure(s) and the risks involved. I understand that I am financially responsible for all services rendered.
I agree to the terms above.
Have there been any changes to the following:
None of the above
Please explain any abnormalities or changes:
What are you feeding your pet? Please list the names and types (wet, dry) of food and all treats given to your pet throughout the day.
List all medications and supplements your pet is currently on, including doses.
Are there any prior illnesses or injuries that we are not aware of?
Does your pet visit any of the following?
Boarding or Day Care
None of the above
Where does your pet spend most of his/her time?
Both Indoors and Outdoors
Do you have other pets at home? If yes, please list what kind below.
Has your pet been seen anywhere else since we last saw your pet? Such as for vaccines or to emergency. If so, where?
Are you or anyone in your household experiencing COVID like symptoms?
Have you been exposed to anyone with COVID?
In case of a medical emergency, in the event that you are unavailable, please choose one:
I authorize the Doctor and staff to perform any life saving measures deemed necessary to save my pet. This includes CPR, any life saving medications or procedures up to $500.
I authorize the Doctor and staff to perform CPR on my pet.
I DO NOT authorize the staff to perform CPR on my pet. I understand that if my pet suffers from cardiac arrest, respiratory arrest, collapse or unconsciousness if CPR is not performed, my pet will pass away.
I have read and understood the information printed above. Please sign below.
Should be Empty: