Mother Lode Veterinary Hospital Shelter Drop-Off Information and Consent for Treatment

Date*

Date

Shelter Name*

Primary Contact Name*

First NameLast Name

Primary Contact Number*

Please enter a valid phone number.

Primary Contact E-mail*

example@example.com

Patient Name*

NCAS ID#

Species:*

DogCatExotic

If you chose exotic, please specify:

Breed:*

Sex:*

Color:*

Temperament:

Foster Name

First NameLast Name

Foster Phone Number

Please enter a valid phone number.

Reason for Transfer to Veterinary Hospital:*

If you chose other, please describe:

Does the patient have a microchip?*

YesNo

Has a heartworm test been performed?*

YesNo

If Yes, was the result positive or negative?

PositiveNegative

Has the pet been started on heartworm prevention?*

YesNo

Has pre-anesthetic lab work been performed?*

YesNo

What time did the patient last eat?*

Hour Minutes

AM/PM Option

Does this pet have any pre-existing medical conditions?*

Is your pet currently on any medications?*

YesNo

If you selected YES, please list medications, the dose, and the last time each medication was given.

Please select the vaccines that are current:*

Please attach proof of current rabies vaccination.

If no rabies information is presented, I understand a Rabies vaccine will be administered at the time of treatment.

Signature*

What medications is this patient currently taking (please include doses if applicable)?

Additional Requests:

Additional Requests (Further Details):

After intake and initial diagnostics, shelter staff will be notified of any anticipated treatment costs for sick or injured animals, as well as any unforeseen veterinary expenses that may arise during routine veterinary care.

I, the undersigned, hereby authorize Mother Lode Veterinary Hospital to provide necessary emergency medical care, diagnostic testing, treatment, and/or surgery as deemed appropriate for the above-listed animal. I understand that this consent includes any emergency treatment or procedures that may be necessary to preserve the health or well-being of the animal.

I acknowledge that the shelter will be responsible for any costs incurred during the care provided by the veterinary hospital unless otherwise arranged.

I confirm that the information provided on this form is accurate to the best of my knowledge. I agree to notify Mother Lode Veterinary Hospital of any changes in the animal's medical history or condition prior to treatment.

I have been informed that there are certain risks and complications associated with sedation, anesthesia, and/or any operation/procedure and that the risks/complications have been explained to me. I further understand that during the course of the operations or procedures, unforeseen conditions may arise that may necessitate the performance of additional procedures deemed necessary by the veterinarian. I am encouraged to discuss any concerns I have about these risks with the attending veterinarian before the procedure is initiated.

I authorize the use of appropriate anesthesia and pain relief medication as needed before, during or after the procedure. I have been informed that there are risks associated with the use of any medication.

The nature of these operations or procedures has been explained to me and I understand what will be done. 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 and given the opportunity to discuss any questions I may have regarding my pet's medical care and my questions have been answered to my satisfaction. I accept that my financial obligations remain regardless of the outcome.

Signature of Authorized Shelter Staff:*

All animals must be picked up before closing. Our office is open Mon-Fri 8am-5:30pm unless otherwise indicated.

Please feel free to add any additional comments or concerns in this section.

Mother Lode Veterinary Hospital Shelter Drop-Off Information and Consent for Treatment

Shelter Information

Patient Information

Foster Information