Clone of Dental Consent Form

Day Admission Form

Shady Brook Animal Hospital
Please verify that you are human*
Enter your information so we can find your account.*

First NameLast Name
Phone Number*
Email
example@example.com
Your Pet's First Name*
Contact Information for Today

Please enter the information for the individual that is able to make and will be responsible for the medical and financial decisions for {yourPets}.
Contact Name:*
Phone Number*
Phone CallText Message
I have read and understand.
Visit Information and Patient History
What is the reason for {yourPets}'s visit today?*
Date {yourPets} will be seen at the hospital:*

MonthDayYear
Date
When was the last time {yourPets} ate?*
YesNo
YesNo
YesNo
YesNo
YesNo
Please list the medications {yourPets} receives and when the last dose was given:
YesNo
Please list the supplements {yourPets} receives and when the last dose was given:
YesNo
Please list {yourPets}'s allergies:
VomitingCoughingSneezingUnusual lumps or bumpsStraining to urinateListless or lethargicDiarrheaStraining to have a bowel movementLimpingNoneSeizuresOther
Please describe the frequency, duration, and details of the symptoms:
Diagnostic bloodworkX-RaysUrinalysisSedation
YesNo
Please explain the other concerns you would like addressed for {yourPets}:
Please explain any additional information that you feel is important for us to know:
Items left at the hospital with {yourPets}:*
Please note that SBAH is not responsible for any lost or damaged items.
I understand and agree to the additional costs that will be applied to my invoice.
YesNo
Please list the medication and the quantity you would like refilled:
In the event that the staff is not able to get in contact with me, I authorize the treatments and procedures the veterinarian deems necessary for the treatment and well-being of my pet, up to a total of $Amount*until I am able to contact the hospital back for further approvals.
CPR/DNR STATUS
As a precaution, any pet that stays in our hospital requires a CPR/DNR status. In the event that {yourPets} should experience cardiac or respiratory arrest while being at our hospital today, do you give consent for resuscitation efforts to be initiated until you can be contacted further and notified of their status? By consenting to this service, you are also acknowledging that certain fees will apply. If you are not able to be contacted immediately, resuscitation efforts will continue to be performed at the veterinarian's discretion. Please select your choice below:*

I agree to CPR being performed in case of arrestI elect a "Do Not Resuscitate" status in case of arrest
Owner Responsibility
I have read and understand
I have read and understand
I have read and understand
Authorization
I authorize the staff of Shady Brook Animal Hospital to perform services including but not limited to the administration of vaccines, medications, lab testing, anesthetics, radiology, pathology, and/or treatments the veterinarian deems necessary for {yourPets}'s health, safety, or well-being while under his/her care and supervision, or emergency circumstances, to follow through with procedures as necessary for {yourPets}'s well-being.*

I have read and understand
I understand that during the performance of the procedures/treatments, unforeseen conditions or problems may be revealed that necessitate an extension of the procedure(s) or that different procedures than those set forth may become necessary. Therefore, I consent to and authorize the performance of any such procedure(s) the veterinarian deems necessary. The staff of Shady Brook Animal Hospital will contact me as soon as medically able to inform me of any changes in {yourPets}'s condition.*

I have read and understand
I have read and understand
I have read and understand
I have read and understand
I have read and understand
Signature of Parent/Guardian*

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Date*

MonthDayYear
Date
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Day Admission Form