Hospitalization Consent Form

Questions

Name*

First Last

Pet's Name*

Phone Number*

Additional Services

Current Meds and Date/Times Last Received:*

Has your pet had food this morning?*

Yes
No

Has your pet had a reaction to any medications/anesthesia in the past?*

Yes
No

Does your pet have a special diet? [If so, please drop-off food]*

Yes
No

Procedure

To determine a diagnosis and begin treatment of an ill animal, certain laboratory testing or radiographs may be required. The veterinarian will call you to discuss these procedures and the associated cost if they have not done this already.

In the event that we are unable to reach you at the contact phone numbers you have provided:*

I allow the vet to run any tests and diagnostics they believe to be medically necessary.
I do not allow the vet to perform any lab tests or take radiographs until speaking with me.

In the event of a life threatening condition, we will make every attempt to stabilize your pet and notify you as soon as possible. In the event that your pet goes into cardiac arrest (heart stops):*

I elect for cardiopulmonary resuscitation (CPR) consisting of but not limited to: chest compressions, intravenous catheter placement, intravenous emergency drug administration, and placement of a breathing tube for ventilation. I understand that these emergency procedures come at an additional cost.
I elect for a DNR (do not resuscitate) status for my pet.

I am the owner or agent for the owner of the animal(s) described on this form and have the authority to execute this consent. I request that the veterinarians, agents and employees of Mainstay Veterinary Practice perform the services which are necessary to the examination, medication and treatment of the animals specifically described and identified on this form. Therefore, I hereby consent to and authorize the performance of such procedure(s) as are necessary in the veterinarian’s professional judgment. I further understand that any animal found to be infected with either external or internal parasites will be treated at my expense. I understand that the treatment of the patient will be conducted with due care and in accordance with the prevailing standards of competency in Veterinary Medicine. I assume financial responsibility for all charges incurred to the patient for services rendered and understand that full payment is required upon discharge. I understand that a written estimate of charges is available within reasonable time at my request.

Authorization*