Hospital Admission and Consent Form
Doctor
*
Dr. Bruno Karam
Dr. Joanna Virgin
Dr. Liz Marchant
Other
Owner Information
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Contact
Secondary Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Information
Name
*
Sex
*
Breed
*
Color
*
Age/Date of Birth
*
Insurance Company (if applicable)
Current Diet (Type, Amount, Times per Day)
Hay
*
Grain
*
Supplements/Medication
*
Vaccine Status
*
Date of Tetanus
*
Patient Items Left
*
Behavior Concerns/Vices
*
Please Read, Agree, and Sign Below
I am the owner, responsible party, or authorized agent, of the above-named animal and have the authority to execute this consent.
*
I agree
I have been informed that there are certain risks and complications associated with any treatments. This has been explained to me and I realize that results cannot be guaranteed. I further understand that during treatment, unseen conditions may arise that may necessitate the performance of additional procedures in exercise of the veterinarian’s professional judgement.
*
I agree
I authorize the use of sedation and medication as needed. I have been informed that there are risks associated with the use of any medication. I understand that the hospital support personnel will be used as deemed necessary by the veterinarian.
*
I agree
I authorize any procedure in addition to or different from this now contemplated, including euthanasia, to avoid cruel and unnecessary suffering by the animal in the event that I am unable to be reached in an appropriate time frame.
*
I agree
I have been informed of the visitation policy. Visting hours are between 9:00am and 5:00pm Monday – Friday and by appointment only Saturday – Sunday for 30 min increments. I acknowledge that I must register with the front desk before visiting and will only interact with my animal.
*
I agree
I have been informed of the trailer loading and unloading policy. I understand that staff members are unable to help load or unload any patients due to safety concerns. Trailers can be parked at the hospital during your animal’s stay. I understand that Pilchuck Veterinary Hospital is not liable for any theft and/or damage to your trailer or its contents. (Please bring your own block and/or tire stops.)
*
I agree
I authorize the use of my animal’s photos for educational and promotional purposes on social media.
Educational purposes
Promotional purposes
Both
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: