HOSPITAL ADMITTANCE/DROP OFF FORM

HOSPITAL ADMITTANCE/DROP OFF FORM

The information requested will tell us the services you want us to provide for you pet. It is the only way we can be certain that we understand what you want. Therefore, it is very important for you to be as specific as possible. In case we need additional information,please give us a phone number where you can be reached TODAY. Thank you.
Today's Date:*

MonthDayYear
Date
Date you are dropping off:*

MonthDayYear
Date
Owners Name:*

First NameLast Name
Owners Phone #, (Please be available at the number provided):*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact *You are authorizing this person to act on your behalf in making health and financial decisions for you pet.:*

First NameLast Name
Emergency Contacts Phone #:*

Area CodePhone Number
Is the address, phone # and email address on your medical record still correct? If not please provide updated information:*
Pets Name being dropped off:*
Please select from the following courses of action:*

Examine my pet only. Do not provide further treatment unless authorized. Iunderstand that if I cannot be reached in a timely manner, my pet may need to board overnight (at my expense) in order to receive the procedures my agent or I approve.Provide any services/treatments deemed necessary by the attending Veterinarian,including vaccinations, blood tests, radiographs and surgery.
I pre-authorize charges to a maximum of:*
$
PLEASE NOTE THE SERVICES REQUESTED FOR YOUR PET *An exam fee is incurred for all examinations by a Doctor. *
SHOULD FLEAS OR TICKS BE PRESENT ON YOUR PET THEY WILL BE TREATED AT YOUR EXPENSE. PLEASE CALL OUR OFFICE IF YOU REQUESTED TO BE CALLED AND HAVE NOT HEARD FROM US BY 4:00 PM

If a health emergency occurs with my pet, I authorize Coffee Road Animal Hospital, INC. to follow through with such procedures as are necessary for the stabilization of my pet and understand I am responsible for payment of these procedures.

I further understand that payment for all services must be made in full at the time of my pet’s discharge.
Signature*

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