CONSENT DROP OFF/ TREATMENT

Date

Your name* This field is required.

First Name

Last Name

Pets name* This field is required.

Patient name

Phone NumberPlease provide a phone number where you can be reached at during the day.

Area Code

Phone Number

Estimate Pricing* This field is required.Estimated Cost: I have a received an estimate for all services to be performed. The dollar amount I am expecting to pay the day of my pet's procedure is:

Procedures to be performed:* This field is required.

Hospitalization

Wellness

Imaging &/ or Diagnostics

Nail trim

Heartworm test

Fecal

Grooming

Other

Additional procedures requested:Please describe procedures or treatments to be performed that have not been listed

Food Allergies: We love to make each visit a positive experience. We would love to reward your pet with a tasty treat while being in the clinic. Is this okay?* This field is required.

Yes, please!

No, thank you.

No, thank you. My pet has known food allergies.

No, thank you. My Pet has known GI sensitivities.

I am aware that RABIES vaccinations are required by state law. Other vaccinations are required by the hospital to protect my pet and others that are hospitalized (Rabies, DHPP, Bordetella, FVRCP, Felv ect.). Due to this law and the concern for public health, my pet is required to be current on all required vaccinations, otherwise, will be vaccinated today. * This field is required.My pet is due for the following vaccinations (Please select all that apply):

DHPP

Bordetella

Rabies

Lepto

Influenza

Not sure

My pet is up to date all vaccinations

FVRCP

FeLV

We take pride in our commitment to maintain top quality medicine and excellent patient care here at Mills Animal Hospital. All patients dropped off for treatment or procedures are checked for fleas prior to entering our kennel. If your pet is found to have fleas, we have permission to treat your pet with a Capstar (*Additional Cost) * This field is required.Please intial

SEDATIVE: In the event your pet needs to be sedated to complete imaging, treatments, or other diagnostics, do we have your permission (additional charge)? * This field is required.

Yes

N/A

CPR: In the event that my pet should experience cardiac or respiratory arrest while being hospitalized, do you give consent for resuscitation efforts to be initiated until you can be contacted further and notified of of your pets status? (Cost: $250-500). 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 be continued to be performed at the doctor’s discretion.* This field is required.Please Note: This disclaimer is provided to all in hospital patients. While we do not anticipate complications, we would like to be prepared in the case of an emergency.

I agree to CPR being performed in case of arrest ($250-500 or More)

I elect a “Do Not Resuscitate” status

Signature: Consent for treatment: I do hereby certify that I am the owner (or duly authorized agent for the owner) of the animal described above, that I do hereby give Mills animal hospital complete authority to perform the above procedure (s). I have been advised as to the nature of the procedure(s) or operation(s) and the risk involved. All of these risks and/or complications have been explained to me. I do hereby forever release the said doctor, agents, servants, or representatives from any and all liability arising from said procedure(s) on said animal. I accept that my financial obligations remain regardless of the outcome. I understand and agree that payment is due in full at time of service and I consent that my animal will not be released from the care of Mills Animal Hospital until said payment is received. In the event my pet is hospitalized overnight, I acknowledge that Mills animal hospital is open/staffed limited hours, and after hours there is no one on-site to monitor my pet. I have been offered transfer to an overnight emergency facility and I have declined. My signature below and my initials certify that I am over eighteen years of age. * This field is required.I have read and understood authorization and hereby accept and agree to the terms of the consent for treatment.

Clear

Signature: Estimate DisclaimerEstimate Disclosure Statement: By signing below I certify that I have read, understand, and have had all of my questions answered to my satisfaction and I agree to the conditions of treatment listed in the estimate provided. I understand that it is only an estimate and the final bill may differ depending on the medical needs of my pet. I am encouraged to discuss all fees related to such care prior to services rendered. I am the owner, agent of the owner, or Good Samaritan responsible for seeking veterinary care for the pet identified, and certify that I am eighteen years of age or over. I do hereby give Mills Animal Hospital complete authority to perform the procedure(s) outlined in the provided estimate. I accept that my financial obligations remain regardless of the outcome. I, understand and agree that payment is due in full at time of service and I consent that my animal will not be released from the care of Mills Animal Hospital until said payment is received.

Clear