Consent for Treatment/Admission

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Client Information

Client's First Name*

Client's Last Name*

Co-Owner First Name

Co-Owner Last Name

Phone*

Email*

Pet Information

Pet's Name*

Species*

Cat

Dog

Breed*

Sex*

Male

Neutered Male

Female

Spayed Female

DOB / Age*

Estimate if needed

I am the owner, authorized agent for the owner, or a Good Samaritan responsible for seeking veterinary care for the animal described above, and I have the authority to execute this consent. My signature below certifies that I am over eighteen years of age.

I have been informed that there are certain risks and potential complications associated with sedation, anesthesia and/or any operation/procedure/treatment/medication that may result in injury, harm or even death from both known and unknown causes. These risks and potential complications have been explained to me to my satisfaction. I further understand that during the course of the operation(s) or procedure(s), unforeseen conditions may arise that may require the performance of additional urgent care services deemed necessary by the attending veterinarian. I am encouraged to discuss any concerns I have about these risks with the attending veterinarian before the procedure is initiated.

Scheduled Treatment Date*

Emergency Care Plan

In the event that my pet requires emergency care during the stay, I understand that the hospital will make every reasonable effort to contact you at the emergency contact numbers provided. However, if I am unable to be reached prior to the time when the performance of the necessary care is deemed to be required by the attending veterinarian, the hospital’s staff has my permission to provide such medical care for my pet up to following amount:*

$200

$700

$2000

General Consent

I authorize the use of appropriate anesthesia/sedation, hospitalization, diagnostic testing, patient monitoring, treatments and medications as needed before, during or after the procedure.

I understand that a treatment plan providing the details and costs for the anticipated veterinary services will be provided to me, at my request, and that I am encouraged to discuss all fees attendant to such care before services are rendered and during my pet’s ongoing medical treatment. In the event that hospitalization is required for more than twenty-four hours for ongoing care, I agree to pay a deposit of 50% of the estimated fees and assume financial responsibility for the balance of all services rendered on a cash, credit card or check basis at the time the pet is discharged from the hospital or the case is otherwise concluded. I understand it is my responsibility to call the hospital at least every twenty-four hours during the duration of hospitalization to inquire as to the medical status of my pet and the fees incurred for medical services up to that day. I understand that veterinary care during nighttime hours and/or weekends is provided at the discretion of the attending veterinarian, and that if required, additional charges may apply. Continuous presence of personnel may not be provided during these hours.

I further agree, that either I, or an authorized agent of mine will promptly pick-up and pay for all accrued charges when I have been notified that my pet is ready to be released from the hospital. I agree that if I fail to comply with this policy within five days of oral or written notification of the readiness to be released, that Companion Animal Hospital may handle this abandonment in the best interests of the pet and/or the hospital in accordance with the local laws and I will still be responsible for all fees incurred.

The nature of these operation(s) and/or procedure(s) has been explained to me to my satisfaction and I understand what will be done. I am aware that the practice of veterinary medicine is not an exact science and I understand that no warranty or guarantee has been either expressed or implied as to a cure or a specific result. I have been encouraged and given the opportunity to discuss any questions I may have regarding my pet’s medical care and my questions have been answered to my satisfaction. I accept that my financial obligations remain regardless of the outcome.

I have read and understand this authorization and hereby accept and agree to the terms of the consent for treatment.

CPR – In the event that your pet should experience cardiac or respiratory arrest while being hospitalized, do you give consent for resuscitative efforts to be initiated until you can be contacted further and notified of his/her status? By consenting to this service, you are also acknowledging that certain fees will apply. If you are not able to be contacted immediately, resuscitation efforts will be continued to be performed at the doctor’s discretion. Please select your choice below.*

I agree to CPR being performed in case of arrest

I elect a “Do Not Resuscitate” status in case of arrest

Elective Procedures During Stay (additional charges apply)*

Please microchip my pet

Please clean my pet’s ears

Please trim my pet’s nails

Please express my pet’s anal glands

Please refill my pet’s Heartworm prevention

Please refill my pet’s Flea/Tick prevention

None of the above

Other

If other, please specify*

Primary Contact First Name*

Primary Contact Last Name*

Preferred Phone Contact Number*

Signature*

Date*

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Client Information

Pet Information

Emergency Care Plan

General Consent

Business Hours

(312) 643-2901