Pet Information
Does your pet have any health concerns at this time?
Is the problem...
Is your pet experiencing any coughing, sneezing, vomiting or diarrhea?Untitled
Are any medications being administered?
If your pet is not current on vaccines, the Dr. will discuss the need for vaccination.
Has your pet experienced any weight loss?
Has your pet experienced any increase or decrease in water consumption?
Is your pet on flea prevention?
Do you have any other pets at home?
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I, the undersigned owner or agent of the owner of , certify that I am eighteen years of age or over and authorize the veterinarian(s) at this practice to perform the above procedure(s). I understand that I am encouraged to discuss any concerns I have about medical risks with the attending veterinarian before the exam/procedure(s) is/are initiated. My signature on this form indicates that any questions I have regarding the following issues have been answered to my satisfaction:
· The reasonable medical and/or surgical treatment options for my pet
· Sufficient details of the procedures to understand what will be performed · How fully my pet will recover and how long it will take
· The most common and serious complications
· The length and type of follow-up care and home restraint required · The estimate of the fees for all services
· Any necessary payment arrangements
While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that veterinary medicine is not an exact science and that no guarantee or warranty has been made regarding the results that may be achieved. I agree to pay a deposit of 50% of the estimated fees, assume financial responsibility for the remaining fees, and provide payment via cash, credit card, or check at the time my pet is discharged from the hospital.
Should unexpected life-saving emergency care be required and the hospital staff is unable to reach me, the staff has my permission to provide such treatment and I agree to pay for such services.
In the event my pet is hospitalized beyond the first day at this facility, I understand that veterinary care during nighttime hours and/or weekends is provided at the discretion of the attending veterinarian. Continuous presence of personnel may not be provided during these hours. If I desire that my pet have supervision when this facility is closed, I elect to pick up my pet and provide such care in my home, in which case I accept all risks of adverse effects or have him/her transferred to a local emergency clinic where overnight veterinary supervision is available at my expense.
I accept that veterinary medicine is an inexact science and that no guarantee of successful treatment has been made. I have read and understand the nature of the above procedures and give my consent to proceed. The most serious complications may include death.
If signs of fleas or live fleas are found on my pet, I understand they will be treated with Capstar to immediately kill the fleas at a cost of $10.
Would you like your pet microchipped for a cost of $40 today?(Required)