Hospitalization Consent Form

Hospitalization Consent Form
Owner's Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Patient's Name*

First NameLast Name
Species*

DogCatSmall Mammal (rabbit, guinea pig, ferret, etc)Other
Sex*

MaleFemale
Neutered/Spayed*

YesNo
Age or Birthday*
Sedation Consent

If sedation is necessary for any reason, the doctor will discuss it with the client before administration.
I hereby authorize the *Veterinary Emergency Center/Leshem Veterinary Surgery to use sedation if/when warranted on the animal described above while hospitalized. I understand that sedation poses a risk to my animal regardless of it's health status. In the event of unforeseen complications, I give permission for the center to take reasonable measures in treating my pet and accept all charges that are incurred as a result of such action. The sedation and relevant costs have been explained to me to my satisfaction.
Signature*

Clear
Unexpected Complications

Please choose ONE option
If unexpected complications arise (choose ONE option):*

CPR: I grant *VEC/LVS permission to perform life saving efforts INCLUDING Cardiopulmonary Resuscitation (CPR) for my animal until I can be reached or the veterinarian on staff deems it necessary to discontinue efforts. I understand I will be contacted as soon as possible. I understand and consent to any additional costs, between $500-$800, that may be incurred above and beyond the estimate due to these efforts. I am aware this still could result in the death of my animal and therefore release and discharge VEC/LVS from any and all liability.DNR: I grant*VEC/LVS permission to perform life saving efforts BUT WITHHOLD Cardiopulmonary Resuscitation (CPR) for my animal until I can be reached. I understand I will be contacted as soon as possible. I understand and consent to any additional costs that may be incurred above and beyond the estimate due to these efforts. I am aware this still could result in the death of my animal and therefore release and discharge VEC/LVS from any and all liability.
Contact Numbers

All numbers provided must belong to an individual authorized to make medical decisions on behalf of the animal listed above in case of emergency.
Phone Number*
Please enter a valid phone number.
Phone Number
Please enter a valid phone number.
Phone Number
Please enter a valid phone number.
Please Read and Review:
Please be aware that with the exception of prescribed medications we do not allow, and are not responsible for, any belongings left with patients. This includes leashes, harnesses, collars, toys, blankets and carriers. Belongings left at the hospital for any reason will NOT be kept for longer than 7 days after check out.*

I understand and acknowledge the above statement.
I consent to the services listed and acknowledge that they have been explained to me. I understand that the low and high sides of this estimate do not directly correlate to the specific number of days a patient spends in hospital as many of the aforementioned diagnostics and/or treatments take place within the first 24 hours of hospitalization.

I acknowledge that I am the owner/authorized agent of the animal described above. I understand this is a reasonable estimate. I further undertand that it is possible that the final invoice may exceed this estimate by as much as 15% and does not include the cost of continued care should it be necessary for the animal described above to remain in the hospital beyond the time frame indicated on this estimate. I also understand I am accepting full financial responsibility and that the full amount due shall be paid upon discharge of my animal.

Estimated fees will be honored up to 60 days.

In the event of default hereunder, the Veterinary Emergency Center/Leshem Veterinary Surgery is entitled to charge and collect interest at the rate of 18% per annum, collections costs, and reasonable attorney's fees.

*For the purposes set forth herein, any reference to VEC/LVS includes it's doctors, nurses, management, and staff.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Hospitalization Consent Form

Sedation Consent

Unexpected Complications

Contact Numbers

Please Read and Review: