Hospitalization / Drop Off Consent Form
Client Details
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Is it okay to text this phone number with updates or reminders?
*
Yes
No
Animal Details
Animal Name
*
Animal Species
*
Animal Breed
*
Animal Age
*
Animal Sex
*
Male
Neutered Male
Female
Spayed Female
Animal Weight
*
General Health Screening
What is your pet being seen for today?
*
Is your pet eating and drinking normally?
*
Yes
No
Please explain
Has your pet experienced any of the following?
Coughing
Sneezing
Vomiting
Diarrhea
Please explain
Have you noticed any changes in your pet's energy level or attitude?
*
Yes
No
Please explain
Is your pet currently on any medications?
*
Yes
No
Please list each one your pet is currently on, as well as date last given, dosage amount, and when the next dose is due
If your pet is due for vaccinations and it is determined that they are well enough to receive them, would you like them administered today for an additional fee?
*
Yes
No
Would you like us to administer them today?
Yes
No
Please list any personal belongings coming into the clinic (please note that we do not recommend any belongings come into the clinic with your pet including bedding, collars, leashes and harnesses as we cannot guarantee it will be returned).
Please check each box to acknowledge each statement below:
*
I understand that some risks always exist with anesthesia and/or surgery
Should some unexpected life-saving emergency care be required, Westlake Animal Hospital staff has mypermission 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 provided to me. I understandthat this is an estimate only and that the cost of surgery or treatment may vary.
I agree to assume full responsibility for the balance of all services rendered with cash, check, or a creditcard at the time my pet is discharged from Westlake Animal Hospital.
If I neglect to pick up my pet within 15 days of the above date, you may assume that the pet isabandoned and Westlake Animal Hospital may assume ownership of pet.
I understand that Westlake Animal Hospital is not staffed between the hours of 7:00pm and 7:00am.
I understand that a 50% deposit is required for all treatments and/or surgeries. If my pet is requiring anovernight stay I understand that all charges will be closed out and processed each night on the credit card Iprovided. Please place my deposit and daily charges on credit card number on file.
Checking this box indicates receipt of estimate.
The vast majority of procedures and hospitalizations have good outcomes and proceed according to plan. In the unexpected event of a sudden decline of your pet’s health, we want to be prepared to respond in a manner that meets your wishes and fulfills your emotional and financial needs.
*
I consent to all costs incurred during the process of resuscitation of my pet. I understand that I will incur charges beyond those included in my agreed upon estimate.
I decline CPR in the event that it is deemed necessary for the survival of my pet. I understand that by choosing this “Do Not Resuscitate” order on my pet, the medical staff will not perform CPR or give possibly life-saving medications.
Signature
*
Submit
Should be Empty: