Fish Creek - Consent Form

Consent Form for Hospitalization
and/or Emergency Surgery

DATE*

Date

What is the name of your regular veterinarian and what hospital are they from? *

OWNER'S NAME*

First NameLast Name

PHONE NUMBER*

Area CodePhone Number

ADDRESS*

Street Address

Address Line 2

CityState / Province

Postal / Zip Code

EMAIL*

example@example.com

PET NAME*

AGE*

SPECIES/BREED*

COLOUR*

SEX*

I, the undersigned owner, am responsible for seeking veterinary care for the pet identified above and certify that I consent to the examination of this pet by veterinarians at Fish Creek Pet Hospital. I also agree that after consultation with me, the hospital's veterinarians may prescribe medication to: treat, hospitalize, sedate, anesthetize and/or perform surgery on my pet. I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure is initiated. Should some unexpected life-saving emergency care be required, and the attending veterinarian is unable to reach me, the hospital staff have my permission to provide such treatment, and I agree to pay for such care.

I understand that an estimate of the costs for veterinary services will be discussed with me 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 agree that either I, or an authorized agent of mine, will pick up my pet within 24 hours of receiving written or oral notification that my pet is ready to be released from the hospital. I agree that if I fail to comply with this policy, the hospital may handle this abandonment in a manner that is in the best interest of the pet and the hospital. I agree that I, or an authorized agent of mine, will pay for all accrued charges when picking up my pet.

Client Signature:

Best Phone Number to Reach You - Please ensure your phone is always on and you are available 24/7. *

Area CodePhone Number

Indicate below your wishes for how you would like our veterinarian to proceed in the event of an emergency situation (heart or respiratory failure):*

Full CPR (potential costs can reach $600 within the first hour)No Resuscitation

CHECKLIST - HAVE YOU TALKED WITH THE VETERINARIAN ABOUT:

The medical and/or surgical treatment alternatives for your pet
Sufficient details of the procedures for you to understand what will be performed
How your pet might respond or recover and how long it could take
The most common and serious complications
The length and type of follow-up care and home restraint required
The estimate of fees for all services

Do you have any financial concerns? If yes, financial concerns must be discussed with the veterinarian prior to admitting your pet to the hospital.*

YesNo

Do you have an insurance policy for your pet? If yes, which company is your policy with so that we can prepare your paperwork:

One of the most important criteria for the delivery of veterinary medical care from the veterinarians and staff members at this practice is a polite, effective, comfortable, and open avenue for communication. I understand that Fish Creek Pet Hospital operates a zero-tolerance policy towards harassment and abuse of all staff.

INITIAL:*

CLIENT INFORMATION

PATIENT INFORMATION