Hospital Admission Form

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Hospital Admission Form

Attached below is a digital form for any patients staying at our hospital for day admissions, sedated or anesthetic procedures.

In an effort to assist with the intake process on the morning of your procedure completion of this form is REQUIRED BY 4 PM on the evening prior to your appointment date. Thank you!

Owners name FIRST, LAST: *

Patient/s name: *

Date of procedure: *

YYYY

Day of Procedure Communication Notice

On the day of your pet/s procedure our surgical team will need to contact you various times throughout the day to provide any updates and review the discharge information. Please read carefully below to ensure all information is reflected accurately so that our team may get in contact upon first attempt:

The best phone number where you can be reached during the procedure:
*

Is the phone number provided above the owner/s or is it for another family/friend/spouse/partner/relative that is allowed to communicate on behalf of the owner for the day? Please select other if its for anyone else that is not the listed account owner.

Self

Other:

Clear selection

Are there any times you are NOT avaliable to talk over the phone so that our team may plan accordingly, please write time or time frame below: *

Emergency contact FIRST, LAST name and contactl

number:

Person(s) authorized to pick up patient/s: *

Self (owner)

Other:

Procedure(s) to be done: *

Did your pet eat the morning of the procedure? *

Yes

On the day prior to the procedure, expected time of last meal? *

List medical conditions:

List any drug allergies:

Current medications (including when the last dose was given):

Anesthesia/sedation consent for patient/s

Our caring veterinarians will perform an exam and obtain pre-anesthetic bloodwork prior to sedating your pet. The safe use of anesthetics depends on the normal function of many vital organs, including the liver and kidneys. The cost of pre-anesthetic bloodwork is included in your estimate.

Your pet's health and safety are our top priority. Advances in anesthesia and anesthetic monitoring have made anesthetic procedures relatively safe, with a low rate of complications. Nevertheless, occasional problems can arise and any anesthetic procedure carries a certain risk that serious complications or even death may result. To minimize the risk of such occurrences, we mandate baseline bloodwork be performed in order to assure proper organ function, clotting ability, detect anemia, or infection, and serve as a baseline for future references. The complete blood count (CBC) is a more sensitive indicator of disease than a physical exam. Additionally, white blood cells (WBC) and platelets can change within hours due to acute infectious diseases. Abnormal glucose levels can increase the anesthetic risk and differ markedly between fasted and non-fasted samples, breed, age, and sick and healthy patients. Evaluating electrolytes, hematocrits, and total protein in fasted patients is essential for monitoring during anesthesia, minimizing the risk of arrhythmias and hypotension, and facilitating patient recovery. As the owner of the patient/s, I certify that I am over 18; and I authorize the staff of this hospital to perform the procedure(s) listed above, as well as those deemed necessary to treat life-threatening emergencies. As with all anesthetics, treatment, and or surgical procedures. I understand there are risks inherent in these services. I acknowledge that staff members at this practice have explained the procedures to me, answered questions to my satisfaction, and can not be held responsible for any unforeseeable results. Further, I am also aware that unforeseen events resulting from anesthesia or procedure(s) will not relieve me from any obligation to all reasonable costs incurred regarding the animal. While I accept that all procedures will be performed to the best abilities of the staff at this facility, I understand that veterinary medicine is not an exact science and that no guarantees have been made regarding the outcome of these procedures. I have read and understand the nature of the above procedures and accept the specific terms and conditions set forth herein.

Dental extractions:

Please read ALL 3 options and select ONLY ONE option if your pet is scheduled for a dental procedure. If your pet is NOT scheduled for a dental please proceed to the next section:

1.) Perform any necessary extractions at this time. I understand my pet may be started on antibiotics and pain medication. I agree to assume financial responsibility for these charges.

2.) Call me after the dental exam and provide an estimate of any additional procedure. I understand that if I cannot be contacted, extractions deemed necessary by the veterinarian will be performed and my pet may be started on antibiotics and pain medication. I assume financial responsibility for these additional charges.

3.) Call me after the dental exam and provide an estimate of any additional procedures. Do NOT proceed without authorization. I understand that if I cannot be reached, no extractions will be performed and I assume ALL responsibility for any complications this decision may cause for my pet. I understand that if I decide to have the additional services done later, I have to schedule for a different appointment with separate charges.

Dental radiographs for DENTAL procedures ONLY:

As the owner, I authorize this hospital to perform dental radiographs at no additional fee.

Yes

Additional services

Please review the options below if you are interested in any additional services being performed on the day of the patient/s procedure.

Required preventive care for hospitalization:

Rabies $30

PureVax rabies (CATS only) $42.00

K9 distemper (DHLPP) / feline distemper (FVRCP) $35.00

Heartworm/lyme/ehrlichia/anaplasma (DOGS only) $68

Elective preventive care and services:

Lyme vaccination $55.00 (booster required in 3-4 weeks if first time)

Influenza H3N2+H3N8 vaccine $62.00 (booster required in 3-4 weeks if first time)

Bordetella vaccine $35.00

Intestinal parasite screen / fecal test $51

Nail trim $25

Ear cleaning $25

Anal gland expression $25

Anti-nausea injection- for patients with a sensitive stomach this injection may reduce post-anesthesia nausea ($ Price varies by weight)

Benadryl injection- for patients with sensitivity to vaccinations this injection may reduce an allergic reaction $25 (Price may vary by weight)

Microchip implant $50

Pet owner release:

The hospital staff members will use all reasonable precautions against injury, escape or death of my pet. I understand that sedation and anesthesia involve some risk to my pet. I will not hold Petvacx or any veterinarian liable in any manner whatsoever or under any circumstances in connection with this procedure. I understand that 24- hour supervision is not provided. I have read this consent form and agree to assume all risks.

Electronic signature acknowledgement:

I, the designated pet owner, agree and understand that by signing the Electronic Signature Acknowledgment and Hospital Admission Form, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement. I further agree my signature on this document is as valid as if I signed the document in writing.

Digital signature consent: (please state full name FIRST, LAST) *

Today's date: *

YYYY

Time: *

Time

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