Clone of Dental Consent Form

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

Preferred Method of Contact During the Day:

I understand that I must be available by phone while my pet is at Shady Brook Animal Hospital so that the veterinarian and/or the staff can communicate with me about {yourPets}'s status and/or obtain consent for recommended diagnostics, treatments, or medications.

Visit Information and Patient History

What is the reason for {yourPets}'s visit today?

Date {yourPets} will be seen at the hospital:

Date

When was the last time {yourPets} ate?

Is {yourPets} on heartworm prevention?

If appropriate, would you like to begin {yourPets} on heartworm prevention today?

Is {yourPets} on flea/tick prevention?

If appropriate, would you like to begin {yourPets} on flea/tick prevention today?

Is {yourPets} presently on medication?

Please list the medications {yourPets} receives and when the last dose was given:

Is {yourPets} taking any over-the-counter supplements?

Please list the supplements {yourPets} receives and when the last dose was given:

Is {yourPets} allergic to any medications, anesthetics, food, or vaccines?

Please list {yourPets}'s allergies:

Has {yourPets} shown any of the following symptoms?

Please describe the frequency, duration, and details of the symptoms:

If deemed medically necessary by the veterinarian, I authorize the following diagnostics for {yourPets}:

Are there any other concerns you would like the veterinarian to address for {yourPets} today?

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.

Please be aware: If fleas or ticks are found on {yourPets} while in the clinic, they will be treated at an additional cost to you

Do you need any refills of medications for {yourPets} today, such as heartworm prevention, flea prevention, or chronic medications?

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:

Owner Responsibility

I understand that home care administered by myself or a designated caretaker may be required to achieve the best overall success.

I understand that I am dropping off {yourPets} at Shady Brook Animal Hospital. I acknowledge that the veterinarian and staff members will be seeing {yourPets} along with scheduled appointments and other drop-offs and that the staff will contact me as soon as possible with an update for {yourPets}.

I agree to pay today, in full, for services rendered, including those deemed necessary for medical or surgical complications or unforeseen circumstances. Furthermore, I understand that regardless of the outcome of the procedures, I am responsible for the payment of the procedures immediately.

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 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 understand that the hospital is not liable for any lost or damaged personal property (leashes, collars, etc.) that is left in the hospital. I understand that I should take all items that I do not wish to be lost or damaged with me.

If I neglect to pick up {yourPets} within 5 days of the date below and do not notify Shady Brook Animal Hospital within that time frame, Shady Brook Animal Hospital may assume my pet is abandoned.

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

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

Signature of Parent/Guardian

Date

Day Admission Form