Clone of Dental Consent Form

1

Enter Your Information So We Can Fetch Your Account* This field is required.PLEASE ENTER THE INFORMATION ASSOCIATED WITH THE ACCOUNT WE HAVE ON FILE.

First Name

Last Name

Phone Number

Email Address

2

Enter Your Information So We Can Fetch Your Account* This field is required.PLEASE ENTER THE INFORMATION ASSOCIATED WITH THE ACCOUNT WE HAVE ON FILE.

First Name

Last Name

Phone Number

Email Address

3

Contact Information For Today* This field is required.Please provide the information for the individual we should contact today if our medical team or doctor needs additional information, treatment approvals, or authorization regarding your pet's care. If this person is not you, they must be authorized to make both medical and financial decisions on your behalf. Any decisions made by the authorized contact will be considered binding as if made by you.

First Name

Last Name

Phone Number

Preferred Method of Communication Today

4

While your pet is visiting our hospital, we kindly ask that you or your authorized contact remain available by phone or text message.* This field is required.Our team may need to reach you with updates, recommendations, or treatment approvals throughout the day. Prompt communication helps us provide timely care for your pet and avoid unnecessary delays in their treatment.

I have read and understand.

5

I understand that the SBAH team will make every reasonable effort to contact me or my designated authorized contact regarding my pet's condition, treatment recommendations, and associated costs. If the hospital is unable to reach me or my designated contact in a timely manner, I authorize the attending veterinarian to perform any treatments, diagnostics, or procedures deemed medically necessary for the health and well-being of my pet, up to the total amount of $ 0.00 * . This authorization remains in effect until I, or my designated contact, am able to communicate with the hospital and provide further instruction.

6

Pet Name* This field is required.Please introduce us to the pet being dropped off today (and the reason you're probably carrying fur on your clothes.)

Pet Name

7

What is the reason for your pet's visit today?* This field is required.

8

When did your pet last eat?* This field is required.

9

Does your pet take any medications or supplements?* This field is required.

YESNO

10

Please list the medications/supplements your pet receives.Please include how much you give them, how often, and when the last dose was given.

11

Does your pet have any known allergies or had an allergic reaction to vaccines?* This field is required.

YESNO

12

Please tell us about their allergies or allergic event.If your pet had a vaccine reaction, please include what symptoms they exhibited.

14

Please explain. Please describe what has been going on with your pet, including when symptoms began, how often they occur, and any other details that may be helpful. The more information, the better—and don't worry, we don't have weak stomachs. 🐾

15

Anything else we should know to help take the best care of your pet today?This is a great place to share any additional concerns, special requests, quirks, or information that may be helpful to our team.

YESNO

16

Please share any additional concerns, special requests, quirks, or information that may be helpful to our team.

17

Does your pet need any medication refills today?* This field is required.Please let us know if your pet needs refills of any medications while they are visiting us today, including heartworm prevention, flea and tick prevention, or any other prescribed medications. If you prefer to have your pet's prescriptions filled online, let us know- and we can either send you a link for the prescription through our online store or have a written prescription created.

YESNO

18

Please enter the medication you would like us to refill.If your pet needs a refill on heartworm and/or flea prevention, please include the quantity you would like.

19

To help protect all of our patients, any pet found to have fleas or ticks while in the hospital will be treated. The cost of treatment will be added to today's visit.* This field is required.

I understand and agree to the additional costs that will be applied to my invoice.

20

CPR/DNR Status* This field is required.As a precaution, any pet that stays in our hospital is required to have a CPR/DNR status. In the event of an unexpected cardiac or respiratory emergency, 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 (that can range from $200 to $400) in addition to the charges for the services rendered from your pet's boarding stay.

I agree to CPR being performed in case of arrest

I elect a "Do Not Resuscitate" status in case of arrest

21

Home Care & Recovery Acknowledgment* This field is required.I understand that follow-up care at home may be necessary to support my pet's recovery and achieve the best possible outcome. I agree to follow all discharge instructions and understand that the success of my pet's treatment may depend, in part, on the care provided by me or my designated caretaker after leaving the hospital.

I have read and understand

22

Drop-Off Appointment Acknowledgment* This field is required.I understand that drop-off appointments allow my pet to be evaluated and treated throughout the day as the veterinarian works between scheduled appointments, procedures, and other patient care responsibilities. While every effort will be made to assess my pet as promptly as possible, I understand that updates and recommendations may not be available immediately. The hospital team will contact me as soon as they have information to share regarding my pet's condition and care plan.

I have read and understand

23

Payment Responsibility Acknowledgment* This field is required.Payment is due in full at the time of service. We accept cash, debit, all credit cards, and pet insurance. We also offer CareCredit or Scratch Pay financing to help make the highest quality care accessible to all our patients. We do not offer in-house payment plans.

I understand and agree that payment is due in full for all the services my pet is provided with today.

24

Pet Belongings Acknowledgment* This field is required.I understand that Shady Brook Animal Hospital is not responsible for the loss of or damage to any personal property left with my pet, including but not limited to leashes, collars, harnesses, blankets, toys, carriers, or other belongings. I acknowledge that any items I do not wish to be lost, damaged, or misplaced should be taken with me at the time of drop-off.

I have read and understand

25

Authorization To Treat* This field is required.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 attending veterinarian deems necessary for my pet's health, safety, or well-being while under their supervision. I also authorize the staff and attending veterinarian to follow through with procedures as necessary for my pet's well-being during emergency circumstances.

I have read and consent.

26

Authorization for Additional Medical Care* This field is required.I understand that unforeseen conditions or circumstances may be discovered during the course of my pet's examination, diagnostics, treatment, or procedure that require additional or different services than those originally anticipated. I authorize the attending veterinarian to perform any procedures, treatments, or diagnostics deemed medically necessary for the health, safety, and well-being of my pet. I understand that the team at Shady Brook Animal Hospital will make every reasonable effort to contact me regarding significant findings, recommendations, and changes to the treatment plan. If additional procedures become necessary, I will be notified as soon as medically appropriate.

I have read and understand

27

No warranty or guarantee has been offered or given to me as to the results or cure afforded by these treatments or procedures.* This field is required.

I have read and understand

28

Abandoned Pet Policy* This field is required.I understand that I am responsible for picking up my pet in a timely manner following today's visit or procedure. If my pet is not picked up within five (5) days and I have not contacted Shady Brook Animal Hospital to make alternative arrangements, I understand that my pet may be considered abandoned. In such circumstances, Shady Brook Animal Hospital may take any actions permitted by applicable law, including transferring ownership, rehoming, or otherwise providing for my pet's care.

I have read and understand

29

I AM AT LEAST 18 YEARS OF AGE. I have read and understand this authorization and have the authority to execute this consent.* This field is required.

I have read and understand

30

Date* This field is required.

Date

31

Signature of Parent/Guardian* This field is required.