Hospitalization (Drop-off) Consent Form

HOSPITALIZATION/DROP-OFF CONSENT FORM

Client Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Is the person listed above the one that our clinic should call to discuss the procedure and discharge information?*

YesNo

If you answered "No" to the above question, please list the name and phone number of whom we should contact:

Patient (Pet) Name*

Species*

Dog/canineCat/feline

Are you 18 years of age or older, and able to consent to the examination of your pet?

I am 18 years of age or olderI am not 18 years of age or older

I, the undersigned ower, or owner's agent, consent to the examination of my pet by staff veterinarians at Point Breeze Veterinary Clinic, Inc. and after consultation with me to prescribe medication for, treat, hospitalize, anesthetize, and/or perform surgery on my animal. I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with my attending veterinarian before the procedure is initiated. Should some unexpected life-saving emergency care be required, Point Breeze Veterinary Clinic, Inc. staff has my permission to provide such treatment and I agree to pay for such care.

I understand that a treatment plan of the costs for veterinary services will be provided to me, if I request it and that I am encouraged to discuss all fees attendant to care rendered and during my pet's ongoing medical treatment. If my pet is hospitalized, I agree to pay a deposit of 50% of the estimate fees and assume financial responsibility for the balance of all services on a 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, I agree to inquire as to the medical status of my pet and the fees incurred for the medical services up to that day. In the event of an open balance, I agree to pay monthly financing fees, including a flat billing fee of $3.00 and a service fee equal to 1.5% (18% per annum) of the unpaid balance.

I further agree that I, or an authorized agent of mine, will pick up my pet and pay for all accrued charges within five days after receiving written and/or oral notification that my pet is ready to be released from the hospital. Such notice will be given at the address maintained on the hospital's patient/client record or the address listed above. I agree that if I fail to comply with this policy, Point Breeze Veterinary Clinic, Inc. may handle this abandonment in the best interests of the animal and the hospital.

By signing below, I hereby authorize the Point Breeze Veterinary Clinic to hospitalize my pet, examine them, and perform diagnostics, which include but are not limited to blood work, urinalysis, x-rays, and/or enemas.

Signature*

Should my pet experience an unexpected critical emergency including (but not limited to) cardiac or respiratory distress, Point Breeze Veterinary Clinic Inc. staff has my permission to provide such treatment and I agree to pay for such care. Please select one:*

Yes, if necessary I authorize Point Breeze Veterinary Clinic to perform emergency treatment including CPR.No, thank you, I would like to place a DNR (Do Not Resuscitate) order on my pet.

Procedure(s):*

Please list any questions or concerns for the veterinarian while your pet is in the hospital:*

Date of Procedure*

Date

What are you currently feeding your pet?*

Please list ALL medications your pet is currently taking, including over-the-counter (i.e. Asprin):*

DOGS ONLY: Are we allowed to walk your dog outside? If so, does he/she have a "potty password" (go on command)?