Drop-off/Hospitalization Form

Name*

First NameLast Name

Phone Number*

We must be able to contact you while your pet is in hospital.

Email*

example@example.com

Patient's Name*

Medications pet is currently on

Please select all things your pet is exposed to at home:

Table scrapsChew and ingest other items than foodPossibly rat poisonAnti-freeze

What changes have you seen at home? Please select all that apply.

When did all this begin?

Enviroment?

Indoor Only (Cats)Indoor/OutdoorOutdoor Only

***WE MUST BE ABLE TO REACH YOU WHILE YOUR PET IS HOSPITALIZED. If for any reason we cannot make contact at the phone number(s) provided, the veterinarian may perform procedures necessary for the health of the patient. I understand C.C. Veterinary Hospital cannot guarantee the health of my pet. I understand that anesthesia and surgery always involve some risk, and agree to hold C.C. Veterinary Hospital harmless, in the absence of negligence, in connection with these procedures. I acknowledge that no guarantee or assurance has been made to me as to the results that may be obtained. If unforeseen conditions arise, in the judgment of the attending veterinarian, require procedures and/or treatment other than those authorized in this release, and staff is unable to contact me or my authorized agent at the phone numbers listed above, I assume full responsibility for treatment costs incurred.I understand that if I, the owner or authorized agent, do not contact C.C. Veterinary Hospital regarding the animal noted on this release after 5 days of the pet's admission to C.C. Veterinary Hospital, said animal will be considered abandoned and may be disposed of as the veterinarian sees appropriate. It is also understood this action does not relieve me of any debt to C.C. Veterinary Hospital for expenses incurred. All procedures must be paid in full at the time of service by cash, check, VISA, MasterCard, Discover, or Care Credit unless prior arrangements have been made and approved.

Date*

Date

Signature*