CLIENT CONSENT FORM

CLIENT CONSENT FORM
Today's Date *

Month Day Year
Date
Client's Information
Name *

First Name Last Name
Emergency Contact Number *
How would you like us to communicate NON- emergency information? *
Cell Number *
Cell Number *
Email *
Email *
example@example.com
Phone Number *
Phone Number *
Address

Street Address

Street Address Line 2

City State

Zip Code
Please list all people authorized to pick up your pet.
Pet's Information
Pet's Name *
Species *
Breed *
Sex *
Parasite Free Enviroment

Please be aware that all pets are checked for fleas and ticks upon admittance. If evidence is found, a Capstar will be given at the owner's expense.
Professional Services
Please select all that apply *

Bath & Brush Canine Boarding Feline Boarding Sick Exam Laboratory Testing Canine Vaccinations Feline Vaccinations Professional Grooming Training-Addtional Paperwork Needed Surgery- Additional Paperwork Needed
Informed Consent

Every year, tens of thousands of Americans will get sick from diseases spread between animals and people. These are known as zoonotic diseases. Zoonotic diseases can be caused by germs including viruses, bacteria, parasites, and fungi. It is important to know that animals do not always appear sick when carrying a zoonotic disease. Many animals can appear healthy, but still be carrying parasites that can make people sick. Stool sample exams, or "fecals," are an important tool to minimize the risk of pets passing intestinal parasites to their owners. We recommend a fecal be done every 6 months for all pets, including indoor-only animals.
Please select one *

I agree to test My pet is not due at this time
Fecal Testing is required every 6 months for all patients staying in our hospital.

All positive test will require immediate treatment and/or result in an additional daily "isolation" fee.
Bath & Brush
Type of Shampoo *

Regular Medicated- ask about pricing
Type of Medicated Shampoo *
Additional Bathing Services- ask about pricing

Dremel Nails Brush Teeth Conditioning Treatment
Canine Boarding
My pet will be boarding from *

Month Day Year
Check-IN Date
My pet will be boarding until *

Month Day Year
Check-OUT Date
Estimated Time of Check-Out *

: Hour Minutes AM/PM Option
*Pick-up after 4pm for pets

recieving Bathing or Grooming
Feed Times *

Breakfast Only Dinner Only Breakfast & Dinner Free Feed
Type of Food *

Science Diet (provided) Special Diet (from home)
Description of Special Diet
Amount of food to be given each day
Cups/day
Is your pet diabetic? *

Yes No
Feline Boarding
My pet will be boarding from *

Month Day Year
Check-IN Date
My pet will be boarding until *

Month Day Year
Check-OUT Date
Estimated Time of Check-Out *

: Hour Minutes AM/PM Option
*Pick-up after 4pm for pets

receiving Bathing & Grooming
Feed Times *

Breakfast Only Dinner Only Breakfast & Dinner Free Feed
Type of Food *

Science Diet (provided) Special Diet (from home)
Description of Special Diet
Amount of food to be given each day *
Cups/day
Is your pet diabetic? *

Yes No
Diabetic Patient Information
When was the last time your pet ate? *

: Hour Minutes AM/PM Option
Type of Insulin Used *
How many units are to be given at each dose? *
Units
How many times each day? *
When was the last dose given? *

Yesterday Today
What time was the last dose given? *

: Hour Minutes AM/PM Option
When does the next dose need to be given by us? *

Today Tomorrow
What time does the dose need to be given by us? *

: Hour Minutes AM/PM Option
Additional Boarding Services

*Please see Client Care Specialist for pricing
Will your pet require medications to be given while boarding? *

Yes No
Please list all medications to be given *
Will you pet be attending PlayCare while boarding? *

Yes No
Please indicate which days your pet will be attending PlayCare *

Monday Tuesday Wednesday Thursday Friday
Will your pet be receiving individual Play Time while boarding? *

Yes No
Please indicate which days your pet will be receiving individual Play Time *

Monday Tuesday Wednesday Thursday Friday Saturday
Will your pet be receiving Extra Walks while boarding? *

Yes No
Please indicate which days your pet will be receiving Extra Walks *

Monday Tuesday Wednesday Thursday Friday Saturday
How many times each day? *
Sick Exam
Please check all symptoms that apply *

Vomiting Diarrhea Scratching Limping Not Eating Not Drinking Excessive Thirst Lethargy Coughing Difficulty Breathing Sneezing Constipation
Please explain reason for visit
Canine Vaccinations
Please select all that apply. *

Distemper 3 Year Rabies 1 Year Bordetella/ Kennel Cough- every 6 mos Leptospirosis
Feline Vaccinations
Please select all that apply. *

Rabies 1 Year Distemper 3 Year Feline Leukemia
Laboratory Testing

*Please bring teaspoon sized stool sample to save money on fecal testing.
Please select all that apply. *

Heartworm Test Fecal Exam Parvo Test Ear Cytology Urinalysis T4 Mini Prep Profile Full Comprehensive Profile Senior Wellness Profile Feline Leuk/Aids Test
Professional Grooming
How would you like your pet groomed? *

Wish to discuss with groomer Same as last time
Type of Shampoo *

Regular Medicated- ask about pricing
Type of Medicated Shampoo *
Additional Bathing Services- ask about pricing

Dremel Nails Brush Teeth
Photo Release

I grant to Cedarcrest Animal Hospital, its representatives and employees the right to take photographs of me and/or my pet, and to copyright, use and publish the same in print and/or electronically.

I agree that Cedarcrest Animal Hospital may use such photographs of me and/or my pet with or without my name and for any lawful purpose, including, for example, such purposes as publicity, illustration, advertising, and Web content.
Please select one *

I GIVE permission I DO NOT give permission
Please list any additional information we should know regarding you or your pet.
Authorization

I, the undersigned owner or agent of the owner of the pet identified above, certify that I AM EIGHTEEN years of age or older and authorize the veterinarian(s) at Cedarcrest Animal Hospital to perform the above procedure(s). I understand that some risks always exist with drug therapy and medical treatments and I have been encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. My signature on this form indicates that any questions I have regarding the following issues have been answered to my satisfaction:
- The reasonable medical treatment options for my pet
- Sufficient details of the procedures to understand what will be performed
- How fully my pet will recover and how long it will take
- The most common and the most serious side-effects
- The length and type of follow-up care and home care required
- The estimate of the fees for all services
- Any necessary payment arrangements
While I accept that all procedures will be performed to the best of the abilities of the staff at Cedarcrest Animal Hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I agree to assume financial responsibility for all fees and provide payment via cash, credit card, CareCredit or check at the time my pet is discharged from Cedarcrest Animal Hospital.
*Should unexpected life-saving emergency care be required and the staff of Cedarcrest Animal Hospital is unable to reach me, the staff has my permission to provide such treatment and I agree to pay for such services and understand that those fees are not included in my estimate.
Please select one *

Has my permission Does NOT have my permission
I have read and fully understand the terms and conditions set forth above.
Please Sign *

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