Hospital Admissions Form

Owner's Name*

First

Last

Pet's Name*

Species*

Age:*

Please indicate the reason for your pet's drop off/hospitalization:

Preventative Care (ex; vaccinations)
Urinalysis
Blood Work
X-Rays
Illness
Injury

If illness or injury, please describe:

Additional comments or concerns?

When was your pet's last meal?

Today AM
Today PM
Yesterday AM
Yesterday PM

What medications (if any) has your pet received in the last 24 hours? (please list the name, amount, and time given):

All pets admitted to our practice must be current on their Rabies vaccination.

My pet is current
My pet is NOT current

A written estimate of anticipated fees has been given/ will be provided to me upon my request. A deposit may be required upon admittance to the practice. I understand all charges shall be paid in full at the time of discharge. By signing below you give American Veterinary Hospital permission to proceed with any diagnostics testing and/or procedures, including sedation, recommended by the Veterinarian.*

I agree

Our practice is to use all reasonable precautions against injury, escape, or demise but will not be held liable or responsible in any manner regarding the care, treatment or safe keeping of the animal.

I understand that I am assuming all risks involved in care and treatment for this animal.*

I agree

I consent to administration of anesthesia as deemed necessary by the doctor.*

I agree

I acknowledge that risks and the possibility of complications exist in any surgical or medical treatment.*

I agree

In admitting my pet(s) for diagnostics, treatment, or procedures, I hereby consent and authorize American Veterinary Hospital to receive, treat and prescribe as deemed necessary.*

I agree

Consent

I agree to the privacy policy.

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414-304-1818

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