Day Admittance Form

Client Name(Required)
We will need to be able to contact you/someone with permission to make medical and financial decisions.
We will need to be able to contact you/someone with permission to make medical and financial decisions.
Is your pet experiencing:
Describe your pet's urination and defecation habits
Change in amounts of stool?

Medication

Please list medication, amount given and how often it is given
Please list supplement, amount given and how often it is given
In order to diagnose your pet's condition, your pet may require blood tests, x-rays, and/or other diagnostic testing. Do you authorize tests if they doctor feels it is warranted? Please confirm below.
I, undersigned owner/agent of the below named and admitted patient, hereby authorize the attending Veterinarian(s), her/his designated associates, assistants and staff to perform diagnostic procedures as they determine necessary for the care of my pet, including but not limited to blood tests, X­rays or other procedures as needed. Further, I authorize the attending Veterinarian(s ), her/his designated associates, assistants and staff to administer such treatment as deemed therapeutically necessary. I also authorize the use of anesthetic agents if needed. Should an anesthetic be necessary, I authorize the placement of an intravenous catheter (if needed) to minimize the risk of anesthesia. I grant you my consent to receive, prescribe for, treat and/or operate upon my pet. You are to use all reasonable precautions against injury, escape or death of my pet, but you will not be held liable or responsible in any manner in connection there with as it is thoroughly understood that I assume all risks.

I understand that the attending Veterinarian will make a reasonable attempt to contact me prior to above mentioned therapeutic procedures being performed. However, failure to complete said connections shall in no way reverse this authorization for treatment. I understand that no guarantee of successful treatment is made, and hereby verify that I have read and fully understand this authorization. Further, I assume financial responsibility for all charges, and agree to pay all charges at the time of the release of my pet from hospital care.

Since we are a multi-vet practice, I understand my pet may be seen by more than one veterinarian. Visitation may be available during my pet's stay and I understand that due to the nature of the hospital setting emergency conditions may alter the length of time or time(s) of day available. It is necessary that I call and confirm visitation before my arrival. Visitation is not allowed for any patient in isolation. I am welcome to call the hospital and speak to a technician during business hours regarding my pet and understand that any diagnoses can only be made by a doctor. A doctor or technician will make every attempt to update me at least once daily during my pet's stay.

In the unfortunate event of cardiopulmonary arrest, I authorize the doctor and medical staff to:
I understand that throughout my pet's hospital stay additional costs may be incurred and that all fees are due when services and medications are rendered and will be paid in full at the time of my pet's discharge from the hospital.