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  • 990 Price Street, Pismo Beach, CA 93449
Pismo Beach Veterinary Clinic

Pismo Beach Veterinary Clinic

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Category: Clinic Forms

Hospitalization / Anesthesia Check-In Form

Posted on March 19, 2013May 16, 2019 by pismobeachvet

Last name: __________________________________          

First name(s): _______________________________

 

Pet name: ___________________________________          

Contact Phone number(s): ___________________

 

  • I hereby authorize the admission of my pet to Pismo Beach Veterinary Clinic for diagnostic procedures, medical treatments, and/or hospitalization. The phone number above is my best contact during this time.
    • [ ] If checked, my pet is being admitted for a procedure requiring anesthesia or sedation.  I give consent for Pismo Beach Veterinary clinic to proceed with anesthesia/sedation on my pet. Though Pismo Beach Veterinary Clinic does everything possible to make anesthesia/sedation safe, I understand that this is never without some inherent risk.
  • Though I understand that every attempt is made to return belongings in their original condition, I assume responsibility for any lost or damaged personal belongings (including leashes, collars, bedding, toys, etc).
  • If my pet has fleas, flea protection will be used so as not to infest other patients in the clinic. The cost will not exceed $35.00.
  • If an emergency occurs, including a life threatening emergency, and I, nor my emergency contact can be reached, I authorize the doctor to do what s/he deems necessary for the care of my pet and agree to pay for such services.
  • If circumstances arise or currently exist under which my pet has a cardiac or respiratory arrest (initial one):

_____  I authorize CPR to attempt to save my pet’s life (additional charges will apply)        

______I elect to not resuscitate my pet (DNR)

  • I am aware that there is no overnight monitoring of patients at Pismo Beach Veterinary Hospital. I am responsible for making arrangements for transfer to an emergency clinic should overnight monitoring be required.
  • All charges are due at time of pick up. In the event that I fail to pay, I understand that I may be subject to all billing and/or finance charges associated with my account and any collections fees and costs incurred.
  • We make every attempt to create accurate estimates. However, unforeseen circumstances may arise in which we may have recommendations beyond your estimate. Please select from the following scenarios:

___A:  Please do whatever you deem necessary for the care of my pet, even if this exceeds my estimate

___B:  Please contact me if it is expected that my estimate will be exceeded by more than $150

___C:  Please contact me if it is expected that my estimate will be exceeded by ANY amount

If you select options B or C, please make sure that you will be AVAILABLE by phone

  • All of my questions regarding the care of my pet have been answered to my satisfaction.

 

 

Signature: ______________________      Date: ____________________________ 

Hospitalization Consent formDownload

Client Registration Form

Posted on March 19, 2013May 16, 2019 by pismobeachvet

Pismo Beach Veterinary Clinic — Client Registration Form

Last Name:  ___________________ First Name(s):  ______________________

Address:  __________________________ City/Zip:  ______________________

Home Phone:  _________________ Cell Phone:  ________________________

Place of Employment:  ___________________ Work Phone: _______________

Driver’s License: ________________________

E-Mail Address:  __________________________________________________

How did you hear about us?  _________________________________________

 

Pet’s Name:  _________________

Species:  Canine □     Feline □      Other: ___________________

Breed:______________________

Color:_______________________

Sex: M □  F □     Altered? Yes □ No □

Date of Birth: _____________

Date of last vaccinations:

Cats:  FVRCP: ________

FELV: _______­­ Rabies: ________

Dogs: DHLPPVC: _________ Rabies: _________

 

Pet’s Name:  _________________

Species:  Canine □    Feline □    Other: ___________________

Breed:______________________

Color:_______________________

Sex: M □  F □     Altered? Yes □ No □

Date of Birth: _____________

Date of last vaccinations:

Cats:  FVRCP: ________

FELV: _______­­ Rabies: ________

Dogs: DHLPPVC: _________ Rabies: _________

Pet’s Name:  _________________

Species:  Canine □     Feline □    Other: ___________________

Breed:______________________

Color:_______________________

Sex: M □  F □     Altered? Yes □ No □

Date of Birth: _____________

Date of last vaccinations:

Cats:  FVRCP: ________

FELV: _______­­ Rabies: ________

Dogs: DHLPPVC: _________ Rabies: _________

 

Pet’s Name: __________________

Species:  Canine □    Feline □    Other: ___________________

Breed:______________________

Color:_______________________

Sex: M □  F □     Altered? Yes □ No □

Date of Birth: _____________

Date of last vaccinations:

Cats:  FVRCP: ________

FELV: _______­­ Rabies: ________

Dogs: DHLPPVC: _________         Rabies: _________

I understand that payment is due at the time of service. I agree to take full financial responsibility for this pet’s medical care.

My preferred method of payment is:  Credit □   Cash □    Check □

Signature: _________________________________________

Client RegistrationDownload

Boarding Check-in

Posted on March 19, 2013 by pismobeachvet

 Boarding Check-in

Last name:___________________  First name(s): _____________________

Address: ______________________________________________________

Home phone: _________________ Cell phone(s): _______________________

Emergency Contact(s): ___________________________________________

Drop-off date: ____________ Pick-up date and time: ____________________

 

Pet name: _______________

Species: ________________

Breed: __________________

Color: __________________

Sex: _________ Altered? ___

Date of Birth: ____________

 

Date of last exam: ________

Date of last vaccinations:

Cats:    FVRCP______

FELV________ Rabies ______

Dogs:   DHPP________Rabies______

Bordetella_________

 

Boarding instructions:

  • With my pet, I also dropped off (circle):  Food            Medications         Bed              Bowl(s)           Toy(s)                         Leash              Other: _________
  • Feeding instructions: Please list type of food, quantity, and frequency:

_______________________________________________________________________________________________________________

  • Medications:  Please list name, dose, and frequency:

_______________________________________________________________________________________________________________

 

Boarding Policy/Consent:

I understand that:

  • Though every attempt is made to return belongings in their original condition, I assume full responsibility for any lost or damaged personal belongings (including leashes, collars, bedding, toys, etc).
  • I must provide proof of a current physical exam (within one year) and vaccination status.  Special exceptions may be made only by doctor approval.
  • If my pet has fleas, flea protection will be used so as not to infest other patients in the clinic.  The cost will not exceed $23.00.
  • If an emergency occurs, and I cannot be reached (or my emergency contact cannot be reached), I authorize the doctor to do what s/he deems necessary for the care of my pet.
  • My pet will be walked at least 3 times daily.  If s/he becomes soiled, s/he will be cleaned.  Any additional bathing will be at my expense.
  • All charges are due at time of pick up.

 

Signature: ____________________________________

Download Document in Word

Click here to download the document in WORD…

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990 Price Street
Pismo Beach, CA 93449
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