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Hospitalization Information Sheet

Client Name:

Patient Name:

Client Phone #:

Client Email:

What is the patient being hospitalized for?

Secondary Contact/Phone Number:

Did you bring the patient any food?

When was the last time the patient ate?

Any known allergies?

Is the patient on any medication?

Is the patient on any medication?
A
B

If yes, please list:

Was any calming medication (i.e. oral Gabapentin / Trazodone) administered prior to patient's procedure today?

Was any calming medication (i.e. oral Gabapentin / Trazodone) administered prior to patient's procedure today?
A
B

If you answered no, are you comfortable with the doctor administering a mild oral calming medication, as deemed necessary by the doctor? Please note that imaging diagnostics require patients to be still for 15-20 minutes, and many patients benefit from these medications.

If you answered no, are you comfortable with the doctor administering a mild oral calming medication, as deemed necessary by the doctor? Please note that imaging diagnostics require patients to be still for 15-20 minutes, and many patients benefit from these medications.
A
B

Special Instructions:

I hereby authorize performance of the services listed above. I understand that I assume financial responsibility of the services rendered and that payment is due upon discharge of my pet.

Signature