Hospitalization Consent Form Are you a new client?(Required) Yes No Please complete our New Client Form before your visit.Owner's Name(Required) First Last Reason for Hospitalization(Required) Best phone number to contact during hospitalization stay(Required)Email(Required) Today's Date(Required) MM slash DD slash YYYY Date of Hospitalization(Required) MM slash DD slash YYYY Pet's Name(Required) Pet's Gender(Required) Male Male (Neutered) Female Female (Spayed) Is this a new pet?(Required) Yes No Pet InformationSpecies(Required) Dog Cat Breed(Required) Color(Required) Age/Date of Birth(Required) Is your pet microchipped?(Required) Yes No Name of Previous Clinic Previous Clinic PhoneMay we request medical records? Yes No Any previous illnesses or surgeries?(Required) Yes No If yes, please explain(Required) Is your pet on any special diets or medications?(Required) Yes No If yes, please list the medication name and dosage and/or any special dietsDid they receive medication this morning?(Required) Yes No Is your pet current on their vaccines?(Required) Yes No My pet(s) need vaccines and I will cover the cost for the vaccines (Required for admission) Has your pet ever had any vaccine reactions?(Required) Yes No Has your pet ever had a seizure?(Required) Yes No Any coughing, vomiting, diarrhea?(Required) Yes No CPR - Your pet may require cardiopulmonary resuscitation (CPR), including cardiac compressions, positive pressure respiration, emergency medications, or other interventions. If I request such emergency procedures, I agree to be held responsible for veterinary services provided to my pet while staff members pursue treatment and try to reach me for further directions. Regardless of my pet’s recovery or survival, I agree to pay CPR fees in addition to other fees already identified by the practice and agreed upon by me. By declining CPR, in the unlikely event my pet becomes unresponsive during anesthesia, I consent to allow my pet to pass away without intervention.(Required) I authorize CPR I do not authorize CPR As the owner or agent of the above animal, 18 years of age or older, I hereby give my consent to Blue Diamond Animal Hospital to hospitalize my pet.(Required) I consent Blue Diamond Animal Hospital staff Veterinary Graduates Awaiting Licensure (VGAL). While they possess the necessary skills and knowledge, it is essential to acknowledge that their licensure is pending. The well being of the animal remains the primary concern. I'm aware of this arrangement and provide consent to proceed.(Required) I have read and understand I, the undersigned, do hereby certify that I am the owner or duly authorized agent for the owner of the animal described above and have the authority to execute this consent. I understand that during the performance of the procedure, an unforeseen situation may arise that necessitates an extension or variance in the procedure set above. I hereby authorize Blue Diamond Animal Hospital to use reasonable care and judgment in performing the procedure. I have been advised as to the nature of the procedures and the risks involved in performing sedation on the above-described animal. I realize that results cannot be guaranteed. I understand that 50% of my agreed upon treatment plan (estimate) is due at time of drop off and the remaining balance is due at time of pick up.(Required) I have read and understand this authorization and consent. I further understand that I assume financial responsibility for all services rendered. Digital Signature(Required) Date(Required) MM slash DD slash YYYY CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
