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: ____________________________
