ECV - Day Admission Form

Name*

First NameLast Name

Email*

example@example.com

Pet's Name*

Breed*

Sex*

Age/Date of Birth*

The above-named patient is scheduled for a day admission appointment. After getting checked in you can depart, the doctor will call you after they complete their exam and initial diagnostic tests to discuss their findings, discuss additional diagnostic recommendations, and the treatment plan. At this point a specific discharge time will be scheduled.

Additional Authorization

It is important that our team can immediately (no voicemail) reach the authorized owner or person responsible for making decisions for your pet.

Primary contact name*

Primary contact telephone number:*

Secondary contact name*

Secondary contact telephone number:*

If we are unable to reach the above individuals, please choose one of the following options:*

do not proceed except to provide urgent or emergency care.proceed with the doctor's recommended diagnostic and treatment plan up to the amount you have authorized.

I authorize up to $blanks* for additional diagnostics or treatments (not included on estimate) if needed.

Cardiopulmonary Resuscitation (CPR) Directive

I understand East Central Veterinarians (ECV) requires a CPR status prior to the start of all procedures so immediate action can take place in the event of cardiopulmonary arrest during, before, or after anesthesia or anytime in our care. The starting cost of CPR is approximately $300.*

I do AUTHORIZE CPR efforts for my petI do NOT AUTHORIZE CPR (DNR) efforts at this time

Financial Authorization

I have been provided with an estimate and understand that this is an estimate, without complications. If complications arise, they will be charged out accordingly. I understand that if my pet is found to have external parasites (fleas, ticks, etc.), my pet will be treated and the cost of said treatment will be charged to my account accordingly. I understand that the balance on the account must be paid in full before my animal is released.*

I acknowledge

I certify that I am the owner of the above-named animal or the responsible party with the authority to execute this consent. *

Date*

DAY ADMISSION FORM