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Hospitalization/Admission Consent Form
Client Name
*
First Name
Last Name
Has your address changed since we last saw you?
*
Yes
No
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Has your phone number or email changed since we last saw you?
*
Yes
No
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Pet Name
*
Have we seen your pet before?
Yes
No
Pet Information
Type of Pet
Dog
Cat
Other
Sex
Male (intact)
Male (neutered)
Female (intact)
Female (neutered)
Breed
Color
Birth Date or Age
Reason for Visit
What is your primary concern today? Please describe in detail including when your pet started exhibiting these symptoms:
*
Describe your pet's attitude and activity level:
*
Normal
Sluggish
Depressed
Hyperactive
Hides under bed
How is your pet's appetite?
*
Ravenous
Increased
Unchanged
Decreased
Not eating
Have you changed your pet's diet recently?
*
Yes
No
Is your pet on a raw diet?
*
Yes
No
What kind of food do you feed your pet at home?
What kind of food do you feed your pet at home?
*
Has your pet's environment changed (e.g. moved cities)?
If your pet has been vomiting or having diarrhea please describe:
Please list any medications your pet is taking:
Please indicate which preventatives your pet is taking:
Please list any preexisting conditions your pet has of which we may not be aware:
If any other person is authorized to make decisions regarding the health and livelihood of your pet, please list their name and contact information:
Authorization
Consent for Examination, Hospitalization, and Treatment:
*
As the owner, or owner’s agent of the above animal, I hereby give my consent to the staff veterinarians at Lone Tree Animal Care Center to examine, and if appropriate, to hospitalize, prescribe medications for, and perform treatments as deemed necessary on my animal. In the event the veterinarian or staff is unable to reach me, I understand it is my responsibility to call the hospital daily to inquire as to the medical status of my pet. I acknowledge that the medical condition of my pet may drastically worsen in a short period of time. I realize that unforeseen events may occur during the period of hospitalization. Should some unexpected life saving emergency care be required, and should the situation or circumstances preclude my being contacted, LTACC’s staff has my permission to provide necessary treatment. I understand that I am responsible for all professional and hospital fees, including fees for medications and diagnostic procedures, and agree to pay, in full, for all services rendered. This responsibility continues in the event my pet fails to recover, dies, or is euthanized. I am encouraged to discuss all fees attendant to the care of my animal before services are rendered, and to request a written estimate of involved fees if one has not been provided to me. Any verbal or written estimate of charges or fees is only a best approximation, and the final charges may be less than or greater than this amount. I agree to pay a deposit of 60% of the estimated fees upon hospitalization, and to pay for the balance of all services rendered on a cash, credit card or check basis upon discharge. I further agree that I, or an authorized agent, will pick up my pet and pay for all accrued charges within 5 days after receiving written or oral notification that my pet is ready to be released from Lone Tree Animal Care Center. Such notice will be given at the address maintained on the hospital’s patient/client record or the address listed below. I agree that if I fail to comply with this policy, LTACC will consider my animal abandoned and will proceed accordingly.
Any verbal or written estimate of charges or fees is only a best approximation, and the final charges may be less than or greater than this amount. I agree to pay for the balance of all services rendered on a cash, credit card or check basis upon discharge. I further agree that I, or an authorized agent, will pick up my pet and pay for all accrued charges within 5 days after receiving written or oral notification that my pet is ready to be released from Lone Tree Animal Care Center. Such notice will be given at the address maintained on the hospital’s patient/client record or the address listed below. I agree that if I fail to comply with this policy, LTACC will consider my animal abandoned and will proceed accordingly.
I understand my pet will be checked for fleas upon arrival. If fleas are noted, LTACC will administer Capstar for immediate treatment, and will also apply a topical prevention that lasts 30 days. I understand the communicable nature of fleas/ticks, and will be held financially accountable for the treatments.
If your pet has been ill, we will most likely want to perform diagnostic testing. This may include blood panels and/or radiographs. Please check the following statements if you approve of these tests prior to contact with our staff. If you do not approve these tests in advance, we will contact you prior to any diagnostics with an estimate.
Radiographs (may range from $129.10-207)
Bloodwork (may range from $175-243)
Is there a financial limit we should be aware of today? Please list it below if so.
*
Financial limit for today's visit
Other people authorized to make decisions and receive information about my pet:
Name and phone number of authorized individuals
Client Signature
*
Signature Date
*
-
Month
-
Day
Year
Date
LTACC Witness Signature:
Submit
Should be Empty: