Download 1 Hospital Admit Form. - Crossroads Veterinary Hospital

CROSSROADS VETERINARY HOSPITAL
20345 SW PACIFIC HWY., SUITE 208
SHERWOOD, OR 97140
TEL:(503)625-4404 FAX:(503)625-5784
E-MAIL: [email protected] FACEBOOK: CROSSROADSVET HOSPITAL
HOSPITAL ADMISSION FORM
OWNER:____________________________________________________________ DATE:_____________________
PET'S NAME____________________________________________________________________________________
CONTACT NAME:_________________________________________________ PHONE #:______________________ OR
TEXT: _______________________________Circle one of the following choices:
Verizon/AT&T/SPRINT/TM/ Other:___________________
WHILE MY PET IS HERE, PLEASE DO THE FOLLOWING:
Hospital/Transfer from EVCOT: _____________Brought IV / MEDS:___________________________
1 - PHYSICAL EXAM______________________________________________________________
ANY SPECIFIC PROBLEMS?____________________________________________________
2 - TREATMENT__________________________________________________________________
3 - ANESTHESIA -SURGERY-SPAY-NEUTER-X-RAY
DENTAL PROCEDURE-CLEANING-POLISHING-EXTRACTIONS_______________________________
NO FOOD OR WATER? ________________
4 - VARIOUS TESTS:
FECAL_____
URINALYSIS - _________ FELV/FIV TEST-_______ HEARTWORM
TEST - _________
5 - NAILS_______________ OWNER CONSENT FOR TRANQUILIZER IF
NECESSARY______
6 - VACCINES:
CANINE - DHPP_______ BORD______ COR ______ LYMES______ RV_____
FELINE - FVRCP ______ FELV ______ FIP ______ RV _______
7 - AVID / RESQ MICROCHIP ________________________
8 - MEDICATIONS DURING HOSPITAL STAY:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
9 - SPECIAL DIET:
____________________________________________________________________________________________
10 - OTHER:
____________________________________________________________________________________________
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Owner:__________________________________________
Pet:_______________________________________
HOSPITAL ADMISSIONS FORM (continued)
I am the owner or agent for the owner of the above animal and have the authority to execute consent. I herby consent to and authorize the
performance of the preceding procedure(s) or operations(s). I understand that during the performance of the foregoing procedure(s) or
operation(s), unforeseen conditions may be revealed which may necessitate and extension of the foregoing procedure(s) or operation(s). In some
cases different procedure(s) or operation(s) may need to be preformed other that those set forth on the previous page above. Therefore, I herby
consent to and authorize the performance of such procedures and or operations as are necessary and desirable in the exercise of the veterinarian’s
professional judgment. I also authorize the use of the appropriate anesthetics and other medications and I understand that the veterinarian will
I assume responsibility for all charges must be paid at the time
of release and that a deposit may be required for any treatments or procedures. Having an intravenous catheter in
employ the hospital support personnel as deemed necessary.
place with fluid support during surgery can help to keep your pets blood pressure up, since this often decreases when a patient is under anesthesia.
The intravenous catheter also allows for quick access to the vein in case of a medical emergency where medications need to be infused quickly. I
understand the importance for an intravenous catheter and acknowledge that one will be placed n my pet based on the veterinarian discretion. I
have been advised as to the nature of the procedures or operation and the risks involve. I realize that the results cannot be guaranteed. I have
read and understood this authorization form and give my consent .
Signature is required when pets have been released to
the hospital.
SIGNED: ________________________________________________________________________________________________
PRE-SURGICAL BLOOD WORK
Because no surgery is without some risk, however small, it is advised to perform presurgical blood work which tests basic organ functions
before any surgery. Knowing how certain body organs, such as the Liver and Kidneys are functioning are important when your pet has to undergo
anesthesia since the body rids the anesthesia via these organs. If one of the organs is not functioning at 100% the veterinarian can adjust the
anesthesia accordingly, decreasing the risk to your pet. In some cases this information may lead the veterinarian to advice against having the
operation preformed. Results will be available to the veterinarian before the surgery and should there be any indication that an abnormality exists,
steps can be taken to help ensure that safe return of your pet. There is an additional charge to run this test and the hospital staff will provide that
information to you. I have read and understand the information about presurgical blood work.
COST IS $52.00
____________YES, I WANT MY PET TO HAVE PRE-SURGICAL BLOOD WORK
_______________NO, I DO NOT WANT MY PET TO HAVE PRE-SURGICAL BLOOD WORK
SIGNED: ______________________________________________________________________________________________
Boarding pets: Crossroads Veterinary Hospital shall exercise reasonable care for the pet delivered by the Owner to our facility for boarding. It is
expressly agreed by the Owner and Crossroads Veterinary Hospital that Crossroads Veterinary Hospital’s liability shall in no event exceed the lesser
of the current chattel value of a pet of the same species or the sum of $200.00 per animal boarded. The Owner further agrees to be solely
responsible for any and all acts or behavior of said pet while it is in the care of Crossroads Veterinary Hospital. Any controversy or claim arising
out of or relating to this contract shall be settled by arbitration in accordance with the rules of the American Arbitration Association, and judgment
upon the award rendered by an arbitrator may be entered in any Court having jurisdiction thereof. The arbitrator shall, as part of his award,
determine an award to the prevailing party of the costs of such arbitration and reasonable attorney’s fees of the prevailing party.
Initials of Owner/Person responsible for said Animal: _________________________Date:__________________
To return to our web site: http://www.crossroadsvet.com/hospitalforms.html
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