Clinic Forms Archives - Pismo Beach Veterinary Clinic

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 form Download

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 Registration Download

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: ____________________________________

Click here to download the document in WORD…

Category: Clinic Forms

Hospitalization / Anesthesia Check-In Form

Client Registration Form

Boarding Check-in

Hours

Phone

Address