Medical-Admit-Form - Centreville

Surgical/Medical Admission Form - Centreville

I am the owner or am responsible for the named patient and have authority to execute this consent. I hereby authorize the performance of the procedures or treatments outlined on the provided estimate.
Owner first & last name
Pet's name
Procedure

Health History
Did patient eat this morning?      Any diarrhea or vomiting?
In heat or pregnant?      History of seizures?
History of heart conditions?
On any medications?   Yes   No

Owner Email*
example@example.com
Any known allergies to drugs? Yes No List of allergies:
Comments/Concerns Items left with patient
Owner Release
I have been advised as to the nature of the procedure/surgery and the risks involved. I realize results cannot be guaranteed. Advances in anesthesia and surgery have made routine procedures relatively safe with few complications. Nevertheless, problems can arise due to pre-existing conditions not evident during routine pre-surgical and dental exams. To minimize these possible problems, Caring Hands highly recommends pre-anesthetic blood work for all surgical and dental procedures requiring anesthesia.

I understand during performance of the procedure/surgery, unforeseen conditions may be revealed that necessitate an extension of the procedure/surgery or a procedure different than set forth. The hospital will make every effort to consult with me prior to any necessary change. Therefore, I consent to and authorize the performance of such procedures/surgeries as necessary and desirable in the exercise of the veterinarian’s professional judgment, and agree to pay for such care.
If it is deemed necessary for my pet to be hospitalized overnight, I understand that I have the option of taking my pet to a 24-hour facility, or keeping my pet at Caring Hands Animal Hospital where there is no overnight supervision.
Should unexpected life-saving emergency care be required and the attending veterinarian is unable to contact me:
   I consent to and authorize resuscitation of my pet: including, but not limited to, CPR, fluids, and the administration of life-saving drugs.
   I decline resuscitation of my pet: do not perform any resuscitative measures on my pet.

Canine patients are walked outside using a double-leash system every 4-6 hours.
   I consent to having my pet walked outside.
   I decline having my pet walked outside.
I agree to be responsible for payment in full of all charges incurred for procedures, treatments, and testing performed on my pet, including treatment for fleas or any other parasites that are present and acknowledge that payment is due at the time the patient is discharged. I further agree in the case of non-payment, I agree to be responsible for the $35 collection fee, as well as a 1.5% service fee that will be added to the account in addition to the entire amount due.
Signature of owner   Signature   Date   Date

Printed name   Type a label
Name and number for contact:   Type a label   ,     Phone Number
Should be Empty:

Rows	What type	Last given	How much	How often
1
2
3

Surgical/Medical Admission Form - Centreville