Hospital Admissions Form

Pet Owner's First/Last Name *

First Name Last Name

Email address to provide an necessary home instructions: *

example@example.com

Pet's Name

Species

Canine Feline

Reason for visit

Surgical Procedure Dental Procedure Drop-off Appointment

For Dental Procedures:

Extract any teeth as recommended by Doctor Call me prior to any extractions, if I cannot be reached, do proceed with extractions. Call me prior to any extractions, if I cannot be reached, do not proceed with extractions

Please note any masses that your pet may be having removed during today's procedure:

Does your pet need to go home with an e-collar or will you provide an e-collar or surgical suit for your pet? *

Please provide a e-collar or surgical suit for my pet I will be bringing my own e-collar for my pet at the time of drop-off. I will be bringing my own surgical suit for my pet at the time of drop-off. My pet does not need an e-collar or surgical suit

Would you like your Pet to be microchipped during surgery?

Yes No, my Pet has already received a microchip No

Please provide the time when your pet last ate (Note: Surgical/Dental patients are asked to not eat after 8pm the evening before procedure):

*

Please note if your pet is exhibiting any of the following: *

Diarrhea Vomiting Lethargy None of the above

Please note details of diarrhea, vomiting, or lethargy:

Lyndhurst Animal Clinic is to use all reasonable precautions against injury, escape, or demise but will not be held liable or responsible in any manner regarding the care, treatment, or safekeeping of this animal.

The foregoing procedure(s) and all associated risks and benefits have been explained to me. I understand that, during the performance of the foregoing procedure(s), unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure(s) or operation(s) or the performance or different procedure(s) or operation(s) in addition to those set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) or operation(s) as are necessary and desirable in the veterinarian's professional judgment to provide the best care for my pet.

I authorize the use of appropriate anesthetics and other medications including pain medications, and I understand that Lyndhurst Animal Clinic support personnel will be employed as deemed necessary by the veterinarian.

I understand that I am assuming all risks involved in the care and treatment of this animal.

I acknowledge that risks and the possibility of complications exist in any surgical or medical treatment. An estimate of anticipated fees has or will be given to me on request.

All animals must be picked up on the specified release date. It is understood that abandonment does not relieve me from the responsibility of payment for services rendered, including the cost of boarding if I need to extend the time of release.

I agree that in the case of nonpayment, all collection and attorney fees necessary to collect this debt will be born by me.

As owner, or duly authorized agent of the owner, of the above named animal, I hereby consent and authorize the clinic to receive, prescribe, treat or operate on this animal. If more treatment than what was originally anticipated is found to be necessary, the clinic will contact me to inform me and receive my authorization for the treatment. If I cannot be contacted or cannot contact the clinic within a reasonable time-frame during the treatment time, I authorize the clinic to proceed with what treatment they feel is best for the health of my animal, and will accept the treatment and any additional charges incurred as a result. *

Yes, I give Lyndhurst Animal Clinic consent to treat my pet. No, I do not give Lyndhurst Animal Clinic consent to treat my pet.

Signature

Clear

Please provide the first and last name of the person you would like to receive updates or whom to call for pick-up: *

First Name Last Name

Best number to reach the above contact: *

Please enter a valid phone number.

Emergency Contact First and Last Name if we are unable to reach you:

First Name Last Name

Emergency Contact Phone Number:

Please enter a valid phone number.

If you would like for us to send you text and/or picture updates while your pet is here, please initial and provide a cell phone number. (Please be aware that normal text/messaging charges may apply)

Yes, please send me txt/photo messages with updates No, please do not send me txt/photo messages with updates

Best phone number to send text/photo messages to:

Please enter a valid phone number.

Hospital Admissions Form

Requirements for Admission

Treatment Consent

Contact Information