Hospital Admission Form

PARKVILLE ANIMAL HOSPITAL

INFORMED CONSENT FOR ADMISSION FOR HOSPITALIZATION, SURGICAL/MEDICAL PROCEDURES, AND GROOMING SERVICES

NAME OF PET: ___________________________________________

DATE:___________________ PHONENUMBER:_________________

                I hereby authorize and direct the veterinarians of the Parkville Animal Hospital to perform the listed procedures and additional diagnostic and/or treatment procedures as deemed advisable for my pet.  The procedures have been explained to me and I understand that no guarantee can be made as to the results or the cure.  I also understand the risks that may be involved in the procedures and that WE DO NOT PROVIDE 24-HOUR SUPERVISION OF PETS .

                I agree that this account is payable IN FULL upon discharge of my pet.   I also agree to assume full responsibility for any destruction of property or equipment that my pet may cause to Parkville Animal Hospital while it is here and agree to reimburse them in full for its value.  It is agreed that past due accounts are subject to a monthly finance charge of 1.75% (21% per year) in addition to all costs of collections, including a reasonable attorney's fee of 30% of the amount owed. I attest that I am the legal owner (or authorized representative) and am of legal age.

SURGICAL/MEDICALPROCEDURES:________________________________

Note: Extra charges apply for those pets spayed while in heat or pregnant, neutered with retained testicles, or over 40 lbs. body weight.  Pain medications will be given as deemed appropriate and will be charged accordingly.

ADDITIONAL SERVICES:

Pre-Anesthetic ScreenTest  (required for pets 1 years & older-See Additional Consent Form)                            Dental Cleaning/Polishing  (diseased or loose teeth will be pulled as needed unless indicated differently below}

*Please note that if you want to be notified prior to extractions, we well gladly schedule consultation at time of discharge and schedule a new surgical appointment for the extraction work at a later time.  This will apply additional charges for hospital stay, anesthesia and the cost of each tooth-extracted etc.  An estimate will be given for the additional charges.

 It is ok to extract diseased or loose teeth without contacting me.                                     Initial _____                                        

  *Please do not extract teeth at this time.                                                                                             Initial _____

          Update Vaccinations:                                                               

                                DAP*                                        

                                Bordetella*

                                Borrelia (Lyme?s)

                                FVRCP*

                                FeLV

                                RABIES*

* These vaccinations are required to be current for routine hospitalization, or boarding, or they will be given.

Heartworm/Lyme/Ehrlichia/Anaplasmosis Test( required prior to surgery - see Additional Consent Form)

                Feline Leukemia/AIDS Test  (required prior to surgery - see Additional Consent Form)

                Fecal + Giardia (Elisa) Examination

                Anal Glands

                Ear Cleaning

                Nail Trim

                Heartworm Preventative Medication

                Flea and Tick Preventative Medication

                Grooming Services

                Microchipping

PLEASE READ BEFORE SIGNING

OWNER SIGNATURE: --------------------------------------------------------------------------------Date -------------------

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