Critter Care Animal Clinic - Authorization for Hospitalization

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The following information is necessary in order that we might serve you better and give you more personal attention. Please fill out the form completely and double check your personal information to be sure everything is current. Thank you.

AUTHORIZATION FOR DAY ADMISSION

I, owner or authorized agent of admitted patient, hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer treatment as necessary to perform the following surgical, dental, or diagnostic procedure, and additional procedures as are considered therapeutically and/or diagnostically necessary. I also consent to the administration of such anesthetic as necessary.

I hereby authorize performance of the following procedure(s):

If further procedures are necessary how should they be handled?

Perform whatever procedures are needed with the understanding there will be additonal charges.Please call me at the number listed below FIRST, but if you cannot reach me, you may proceed with any additional procedures with the understanding of additional charges.Please DO NOTHING else unless you reach me first. I understand you will wake my pet without doing even the simplest procedure.

The clinic hours are 7:30 AM to 5:30 PM during weekdays, and 7:30 AM to 12:00 PM on Saturdays and your pet will need to be picked up before closing time as staff is not present outside of these hours.

In the event that my pet needs to stay overnight, I have been given the option of having my pet transferred to a 24-hour referral facility. I understand my pet will not be supervised here overnight and have been informed of the associated risks.

I further understand that no guarantee of successful treatment is made. I hereby certify that I have read and understand this authorization, the reasons that this procedure is considered necessary, as well as its advantages and possible complications if any. I will not hold Critter Care Animal Clinic, the doctors, or the staff liable for any complications. I understand that if my pet is not current on his/her rabies vaccination, it will be updated at the time of service. I also understand that any patients found to have fleas will be treated at the owner's expense

I understand that there may be risk involved in these procedures, especially with sedation. In the event of acardiopulmonary arrest (loss of normal heart beat and breathing), I understand immediate action must be taken. I authorize the following.

Cardiopulmonary Resuscitation (CPR) as deemed necessary by the doctor to try to restore normal heart beat &breathing. (Additional charges will apply).No resuscitation efforts.

I assume financial responsibility for all charges incurred to the patient and agree to pay all charges at the time the patient is discharged.

In order to service your pet, the following statements must be checked. Please ask an employee if there are questions.

I agree to pay the exam fee of $95.00 for current patients or $125.00 for new/returning patients. (Additional fees may be accrued for services provided).Additional fees may apply if you do not pick up your pet within regular business hours listed above.

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