Hospitalization Consent Form

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Pet's Name *

Species*

Weight*

Birth Date / Approximate Age*

Breed*

Sex*

CONSENT FORM
I understand that my pet is being hospitalized under the direct care of the
doctors and staff of Cape Veterinary Hospital. An estimate has been
provided to me regarding the proposed diagnostics and/or treatment of my
pet. I agree to pay on-half of the estimated fees and assume responsibility
for the balance of all services rendered on cash, credit card or check basis
at the time my pet is discharged from the hospital.

In the event my pet is hospitalized for more than 48 hours and my attending
doctor is unable to reach me, I understand it is my responsibility to call the
hospital at least every 48 hours.

While every reasonable precaution will be taken to ensure the safety of your
pet, some conditions can worsen unexpectedly.

While your pet is staying at our hospital would you like to receive updates from our staff via*

PhoneTextE-Mail

Please provide the best contact phone number(s)*

Can we call you at any hour?*

YesNo

If no, which hours are available?

A staff member will be calling you each morning with an update on your pet and the proposed plan for the day. Each evening a technician will call you with an update on your pet and the current total of your invoice.

CPR/DNR Orders*

PROCEED with CPR (additional costs will be incurred)DNR (if your pet arrests, we will let them pass)

If publicly posted information about Cape Veterinary Hospital or my pet’s medical care is found to be false or misleading (at the sole discretion of Cape Veterinary Hospital), then I understand that CVH reserves the right to respond in a public manner to release and promote relevant information to ensure the public’s understanding and correction of such false claims.

I Acknowledge This StatementI Do Not Consent (treatment may be denied, a hospital representative will call you to discuss your selection)

Your pet will be monitored by our highly trained nursing team, and while our doctors are available by phone, between the hours of 12am and 7am, there will be no doctor on-site and so cases it is recommended that patients that require more advanced care be transferred to another emergency veterinary hospital with an ICU and overnight veterinarians. By agreeing to admit your pet, you are acknowledging that CPR and advanced life-saving measures will be unavailable during these hours.

Clear