Hospitalization Agreement

Client's Name(Required)

Pet's Name(Required)

Today's Date(Required)

Phone(Required)

Secondary Phone

I hereby authorize Your Veterinary Practice- to receive my pet for care at its facilities.

I consent to my pet’s hospitalization for medical treatment and care. I authorize Your Veterinary Practice- and staff to administer treatment and perform such procedures, including anesthesia, as well as therapeutic and/or diagnostics services necessary for the care of my pet. I authorize Your Veterinary Practice to obtain any medical information from the previous veterinarian or care provider that may be needed during my pet’s stay in the hospital.

It is Your Veterinary Practice’s policy that all animals entering the hospital must be up to date on all vaccinations and free of parasites (fleas, ticks, etc.). If not, the animal will be treated upon entry at(Required)

Please Initial

It is Your Veterinary Practice’s policy to provide the best care possible for my pet, which includes taking all precautions necessary to ensure my pet’s safety and well-being. In keeping with these standards, I have been advised as to the procedure or treatment(s) to be performed on my pet, as well as the deposit due. Any medical treatment presents risks, and the required medical standard of care may not yield positive results. I have been advised of these risks, and after consideration, I understand and assume these risks.(Required)

Please Initial

Your Veterinary Practice’s staff will make every effort to contact you and advise of your pet’s medical condition, if during the planned treatment, your pet needs emergency medical treat or becomes progressively ill. However, if Your Veterinary Practice is unable to contact you, Your Veterinary Practice will proceed with required emergency medical treatment, which may include life-sustaining measures. You will be responsible for any cost or expense incurred.(Required)

Please Initial

Your Veterinary Practice’s normal hours of operation are from 7:00AM until 12AM. These hours may change at Your Veterinary Practice’s discretion. If my pet requires supervision and exceptional care outside the normal hours of operation, an overnight technician may be assigned, if available, or my pet may be referred to a 24-hour hospital. If my pet requires supervision or medical care outside of normal hours of operation, and an overnight technician is available, I am responsible for the additional charges and expenses associated with the care provided to my pet. Regular staff will not be attending to my pet outside of normal hours of operation.(Required)

Please Initial

Your Veterinary Practice will perform all procedures and services to the best of the staff’s abilities. I understand that no guarantee or warranty has been made regarding the results that may be achieved. I also assume full responsibility for any additional expenses incurred after hospitalization, such as, but not limited to follow up radiographs, re-check physical exams and additional medications. I agree to comply with Your Veterinary Practice’s discharge instructions to reduce the likelihood of incurring additional expenses for failing to do so.(Required)

Please Initial

Do we have your permission to post photos of your pet online?(Required)

YES Your pet’s picture or video may be taken while they are with us and used for Your Veterinary Practice advertisement (www.truecompanionvetcare.com) or other social media purposes (Facebook, SnapChat, Twitter,Tiktok, Instagram, etc.)

NO If you do not authorize for your pet’s picture to be included in our marketing materials/venues, we may still use a picture of your pet in our patient records for our internal identification only.

In the event of an emergency do we have permission to perform CPR on your pet?(Required)

Yes, please perform CPR on my pet. (There will be an additional fee of $400) I understand that no guarantee of successful resuscitation or treatment will be made or implied.

No, DO NOT perform CPR on my pet.

COVID Precautions:

Have you, or anyone that you have had close contact with, tested positive for COVID-19 in the past 14 days?(Required)

Yes

Have you or anyone in your house experienced the following symptoms in the past 14 days?

None

Cough

Shortness of Breath

Fever

Sore Throat

Chills

Muscle Pain

Headache

New loss of taste or smell

Who experienced these symptoms?

No Symptoms

Self

Someone Else

Please Initial(Required)

If you are ill or have been exposed to someone who is ill, we require that a family member or friend bring your pet to their appointment.

I am at least 18 years of age and the rightful owner or duly appointed agent for the pet subject to Your Veterinary Practice’s care. I have been provided an estimated cost for the hospitalization, listed above. I have read and fully understand the terms and conditions set forth above.(Required)

Signature of owner/authorized agent: