Hospitalization and Treatment Consent

Hospitalization and Treatment Consent
CLIENT INFORMATION
Client Name*

First NameLast Name
Patient's Name*
Species*
Breed*
Gender*
Age*
Items left with Pet*
REASON FOR VISIT (choose below)
Choose ALL that apply*

Wellness/ VaccinesExam/ SickTechnician VisitLaser TherapyOther - Please elaborate below
If "Other", please elaborate:
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PLEASE READ THIS SECTION CAREFULLY:

VACCINATION POLICY: Our hospital recommends that your pet be current on their distemper and rabies vaccinations. We require that in-patients be current on rabies. Proof that a rabies vaccine has been given by a veterinarian is required at admission. If your pet is overdue for the rabies vaccine, it will be updated pending confirmation of a healthy animal.

FLEA POLICY: Pets with fleas will be treated in the clinic at additional cost.
ADDITIONAL SERVICES OFFERED:

Please choose, BELOW, ALL procedures you WOULD LIKE PERFORMED today.
Choose ALL that apply*

Intestinal Parasite ScreeningEar CleaningFelv/FIV TestRabies VaccineKennel Cough VaccineHWT (heartworm test)Anal Gland ExpressionNail TrimDistemper VaccineMicrochip IdentificationFlea & Tick PreventionDewormingFeline Leukemia VaccineHeartworm PreventativeSenior Pet Lab WorkLaser TherapyOther
If "Other", elaborate
Prescription Refill Request: (please list medications that are requested
ADDITIONAL COMMENTS/ CONCERNS
CONSENT TO TREATMENT:

I am the owner or agent for the owner of the above-described animal and have the authority to execute this consent. I hereby authorize Heartland Veterinary Clinic to perform the procedure(s) listed above. I understand that during the performance of the foregoing procedure(s), unseen conditions may be revealed that necessitate an extension of the foregoing procedure(s) that are set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) as are necessary and desirable in the exercise of the veterinarian’s professional judgment. I also understand that I will be responsible for full payment of services at the time my pet is discharged from the hospital.

I have read and understand this authorization and consent, and being of legal age, I hereby consent and authorize this hospital and its veterinarians and staff to perform the agreed to procedures.

ESTIMATES AVAILABLE UPON REQUEST
EMERGENCY CONTACT NUMBERS (1)*

Area CodePhone Number
EMERGENCY CONTACT NUMBERS (2)

Area CodePhone Number
Date*

MonthDayYear
Client Signature*

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