{"id":3388,"date":"2022-06-15T14:56:32","date_gmt":"2022-06-15T14:56:32","guid":{"rendered":"https:\/\/713websites.com\/?page_id=3388"},"modified":"2022-06-15T14:56:35","modified_gmt":"2022-06-15T14:56:35","slug":"hospitalization-agreement","status":"publish","type":"page","link":"https:\/\/713websites.com\/hospitalization-agreement\/","title":{"rendered":"Hospitalization Agreement"},"content":{"rendered":"<script type=\"text\/javascript\">var 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description_below'><div id=\"field_9_1\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_1\" ><label class='gfield_label gform-field-label' for='input_9_1'>Client&#039;s Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_9_1' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_9_3\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_3\" ><label class='gfield_label gform-field-label' for='input_9_3'>Pet&#039;s Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_9_3' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_9_6\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_6\" ><label class='gfield_label gform-field-label' for='input_9_6'>Today&#039;s Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_6' id='input_9_6' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_9_6_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_9_6_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_9_6' class='gform_hidden' value='https:\/\/713websites.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_9_4\" class=\"gfield gfield--type-phone gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_4\" ><label class='gfield_label gform-field-label' for='input_9_4'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_9_4' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_5\" class=\"gfield gfield--type-phone gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_5\" ><label class='gfield_label gform-field-label' for='input_9_5'>Secondary Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_9_5' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_9_7\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_7\" ><h3 class=\"gsection_title\">I hereby authorize Your Veterinary Practice- to receive my pet for care at its facilities.<\/h3><div class='gsection_description' id='gfield_description_9_7'>I consent to my pet\u2019s 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\u2019s stay in the hospital.\n<\/div><\/div><div id=\"field_9_8\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_8\" ><label class='gfield_label gform-field-label' for='input_9_8'>It is Your Veterinary Practice\u2019s 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<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_9_8' type='text' value='' class='small'  aria-describedby=\"gfield_description_9_8\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_9_8'>Please Initial<\/div><\/div><div id=\"field_9_9\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_9\" ><label class='gfield_label gform-field-label' for='input_9_9'>It is Your Veterinary Practice\u2019s policy to provide the best care possible for my pet, which includes taking all precautions necessary to ensure my pet\u2019s 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.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_9_9' type='text' value='' class='small'  aria-describedby=\"gfield_description_9_9\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_9_9'>Please Initial<\/div><\/div><div id=\"field_9_10\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_10\" ><label class='gfield_label gform-field-label' for='input_9_10'>Your Veterinary Practice\u2019s staff will make every effort to contact you and advise of your pet\u2019s 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.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_9_10' type='text' value='' class='small'  aria-describedby=\"gfield_description_9_10\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_9_10'>Please Initial<\/div><\/div><div id=\"field_9_11\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_11\" ><label class='gfield_label gform-field-label' for='input_9_11'>Your Veterinary Practice\u2019s normal hours of operation are from 7:00AM until 12AM. These hours may change at Your Veterinary Practice\u2019s 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.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_9_11' type='text' value='' class='small'  aria-describedby=\"gfield_description_9_11\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_9_11'>Please Initial<\/div><\/div><div id=\"field_9_12\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_12\" ><label class='gfield_label gform-field-label' for='input_9_12'>Your Veterinary Practice will perform all procedures and services to the best of the staff\u2019s 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\u2019s discharge instructions to reduce the likelihood of incurring additional expenses for failing to do so.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_9_12' type='text' value='' class='small'  aria-describedby=\"gfield_description_9_12\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_9_12'>Please Initial<\/div><\/div><fieldset id=\"field_9_15\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_15\" ><legend class='gfield_label gform-field-label' >Do we have your permission to post photos of your pet online?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_15'>\n\t\t\t<div class='gchoice gchoice_9_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='YES  Your pet&#039;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.)'  id='choice_9_15_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_15_0' id='label_9_15_0' class='gform-field-label gform-field-label--type-inline'>YES  Your pet&#8217;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.)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='NO If you do not authorize for your pet\u2019s 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.'  id='choice_9_15_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_15_1' id='label_9_15_1' class='gform-field-label gform-field-label--type-inline'>NO If you do not authorize for your pet\u2019s 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.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_16\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_16\" ><legend class='gfield_label gform-field-label' >In the event of an emergency do we have permission to perform CPR on your pet?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_16'>\n\t\t\t<div class='gchoice gchoice_9_16_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='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.'  id='choice_9_16_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_16_0' id='label_9_16_0' class='gform-field-label gform-field-label--type-inline'>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.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_16_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='No, DO NOT perform CPR on my pet.'  id='choice_9_16_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_16_1' id='label_9_16_1' class='gform-field-label gform-field-label--type-inline'>No, DO NOT perform CPR on my pet.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_9_17\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_17\" ><h3 class=\"gsection_title\">COVID Precautions:<\/h3><\/div><fieldset id=\"field_9_18\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_18\" ><legend class='gfield_label gform-field-label' >Have you, or anyone that you have had close contact with, tested positive for COVID-19 in the past 14 days?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_9_18'>\n\t\t\t<div class='gchoice gchoice_9_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Yes'  id='choice_9_18_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_18_0' id='label_9_18_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_9_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='No'  id='choice_9_18_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_9_18_1' id='label_9_18_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_20\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_20\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Have you or anyone in your house experienced the following symptoms in the past 14 days?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_9_20'><div class='gchoice gchoice_9_20_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.1' type='checkbox'  value='None'  id='choice_9_20_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_20_1' id='label_9_20_1' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_20_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.2' type='checkbox'  value='Cough'  id='choice_9_20_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_20_2' id='label_9_20_2' class='gform-field-label gform-field-label--type-inline'>Cough<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_20_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.3' type='checkbox'  value='Shortness of Breath'  id='choice_9_20_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_20_3' id='label_9_20_3' class='gform-field-label gform-field-label--type-inline'>Shortness of Breath<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_20_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.4' type='checkbox'  value='Fever'  id='choice_9_20_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_20_4' id='label_9_20_4' class='gform-field-label gform-field-label--type-inline'>Fever<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_20_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.5' type='checkbox'  value='Sore Throat'  id='choice_9_20_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_20_5' id='label_9_20_5' class='gform-field-label gform-field-label--type-inline'>Sore Throat<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_20_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.6' type='checkbox'  value='Chills'  id='choice_9_20_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_20_6' id='label_9_20_6' class='gform-field-label gform-field-label--type-inline'>Chills<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_20_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.7' type='checkbox'  value='Muscle Pain'  id='choice_9_20_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_20_7' id='label_9_20_7' class='gform-field-label gform-field-label--type-inline'>Muscle Pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_20_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.8' type='checkbox'  value='Headache'  id='choice_9_20_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_20_8' id='label_9_20_8' class='gform-field-label gform-field-label--type-inline'>Headache<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_20_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.9' type='checkbox'  value='New loss of taste or smell'  id='choice_9_20_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_20_9' id='label_9_20_9' class='gform-field-label gform-field-label--type-inline'>New loss of taste or smell<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_9_21\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_9_21\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Who experienced these symptoms?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_9_21'><div class='gchoice gchoice_9_21_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.1' type='checkbox'  value='No Symptoms'  id='choice_9_21_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_21_1' id='label_9_21_1' class='gform-field-label gform-field-label--type-inline'>No Symptoms<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_21_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.2' type='checkbox'  value='Self'  id='choice_9_21_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_9_21_2' id='label_9_21_2' class='gform-field-label gform-field-label--type-inline'>Self<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_9_21_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.3' type='checkbox'  value='Someone Else'  id='choice_9_21_3'   \/>\n\t\t\t\t\t\t\t\t<label 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