Drop-Off Appointment Consent Form

Drop-Off Appointment Consent Form
I hereby certify that I am the owner or authorized representative of the below-named pet, that I am 18 years of age or older, and that I have the authority to execute this consent.

I also agree that after consultation with me, the hospital’s doctors may medicate, treat, hospitalize, sedate, anesthetize and/or perform surgery on my pet. I understand and accept 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 the attending veterinarian before the procedure is initiated.

I understand that a staff member will prepare a fee estimate describing the recommended medical services and that I am encouraged to discuss all fees before services are rendered. Although estimates cannot always predict actual costs, I agree to the written estimate of costs provided to me within a 25% range.
Pet Information
Your Pet's Name*
Species*
Breed*
Color*
Age*
Sex*
Contact Information
Name*

First NameLast Name
Phone Number*
Failure to be reached today may result in cancellation or delay of your pet's procedure.
Email*
example@example.com
Alternate Contact Name (if applicable)

First NameLast Name
Alternate Contact Phone
If you are unable to be reached this person may be asked to make decisions for your pet.
In the rare event that your pet should experience cardiac or respiratory arrest while in our care today, do you consent to resuscitative efforts to be initiated until you can be contacted further about your pet's status? By consenting to this service, you are also acknowledging that additional fees may apply. If we are not able to reach you, resuscitation efforts will be performed at the doctor's discretion. Please choose ONE option below*

I agree to CPR being performed in case of arrestI elect a Do Not Resuscitate status in case of arrest
Valley Center Veterinary Clinic requires a Drop-Off Appointment Reservation Fee in the amount of $68 to hold an inpatient appointment slot, to be paid prior to said appointment. Should your final invoice be less than the fee paid, the difference will be refunded. I agree to pay this fee and assume financial responsibility for the balance of all services rendered at the time the pet is discharged from the hospital.
Treatment Authorization Statement

I have been advised as to the nature of the procedure(s) or operation(s) and the risks involved. I am aware that the practice of veterinary medicine is not an exact science and, thus, there are no guarantees for successful treatment. I have been encouraged to discuss any questions I may have, had them answered to my satisfaction, and accept that my financial obligations remain regardless of the outcome.
I have read and understand this authorization and hereby consent to the recommended care.
Signature*

Clear
Date*

MonthDayYear
I have received, reviewed and approved the procedure estimate presented to me today.*

Initial for Financial Consent
I have received, reviewed and approved the procedure estimate presented to me today.
Initial for Financial Consent*

Drop-Off Reservation Policy: I agree to pay a $68 fee to hold my pet's inpatient appointment, which will then be applied to my invoice balance.
Initial for Financial Consent*
Drop-Off Deposit Policy: I agree to a $200 deposit at the time of drop-off, which will then be applied to my invoice balance. I agree to pay the remaining balance upon pick-up. Should the final invoice be less than the deposit, the difference will be refunded.*

Initial for Financial Consent
Should be Empty:

Drop-Off Appointment Consent Form

Pet Information

Contact Information

Treatment Authorization Statement