PET HOSPITAL ADMISSION FORM

Owner Name & Surname*

First NameLast Name

Account Name or Profile name or number

Contact Name and Number 1*

Contact Name and Number 2

Pet Name *

Species*

Sex*

MaleFemale

Sterilised *

YesNo

Breed

Color

Markings

Pet Date of Birth

Date

Age *

Weight

Microchip

Medical Aid name and number (if applicable)

Additional Remarks (eg. Allergies, Chronic Diseases)

Reason for Admission *

Is your pet currently on any medication

If so, please specify

Has your pet had a reaction to any medication or an anesthetic or sedative in the past?*

Has your pet (to your knowledge) been exposed to any animal that might have a contagious disease: i.e. Parvo, Distemper, Rabies?

Add on procedures: Please note additional procedures will cost extra. Feel free to discuss this with us when your pet gets admitted on the day.*

Any other concerns ?

Indemnity & Consent (POPIA Compliant)

I, the undersigned, being the owner of the or duly authorized person, give my consent for the above-mentioned procedure/s, and any other procedure that should become necessary. The use of modern anesthetic techniques minimizes the risk; however, all anesthetic procedures carry some risk. I understand that, under emergency circumstances (including general treatments of exotic pets), it may be necessary to give unlicensed medication and give consent to the use of such drugs where necessary.

It is often not possible to accurately estimate total cost as additional treatments may become necessary during the procedure. Should the estimated fee increase, we will endeavor to contact you, however, should this not be possible, we will proceed in a manner that is in the best interest of the patient.

My pet is up to date with its vaccinations. If not, I absolve Underberg Veterinary Surgery of any responsibility if my pet should contract any infectious diseases covered by vaccination. Underberg Veterinary Surgery is not responsible for any belongings left with my pet in the hospital.

I hereby consent to and authorize this veterinary surgeon, and his/her practice to share my personal and account payment information and history with any third party. Iunderstand and acknowledge that treatment may be refused due to non-payment. The refusal of treatment due to the non-payment of accounts will include, but will not be limited to, the refusal of administering any emergency and/or after- hours treatment required by my animal. Iunconditionally indemnify Underberg Veterinary Surgery and its staff/volunteers against any loss, liability, or damage of whatsoever nature (whether direct, indirect, or consequential) that may result from the sharing of/accessing of my account information in this regard, including but not limited to the death of my animal due to the refusal of any veterinarian from treating the animal because of my negative account history (if applicable I understand that this practice operates on a cash-only basis, no other sales will be done if I have an outstanding account, furthermore that the relevant administration fees will be charged.

Disclaimer: Underberg Veterinary Surgery will not sell, trade, barter or distribute the information with any third party, except in case of non-payment or regards to the treatment of the animal.

I UNDERSTAND THAT FULL PAYMENT IS DUE ON COLLECTION OF MY PET. SHOULD I NOT HAVE AN ACCOUNT

WITH UNDERBERG VETS, A DEPOSIT MAY BE REQUIRED PRIOR TO THE PROCEDURE BEING PERFORMED.

An estimate of the cost for this and additional procedures have been discussed with me prior to admission:

Estimate

Deposit

I agree to the terms & conditions

Signature*

Date*

Date