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SX Ortho Intake Form Just PT

Keith Blass, DVM, DACVIM (Cardiology)

Jacqueline Gest, DVM, DACVIM (Internal Medicine)

Ariel Kravitz, DVM, DACVS- SA, CVA (Surgery)

Carol Margolis, DVM, DACT (Theriogenology)

Victoria Kearns, LVT, CCRP, NCM, OACM (Rehab)

Riley Palmese, LVT, CCAT (Rehab)

Owner Name:

Address:

Pet's Name :

Patient ID:

Species:

Breed:

Color:

Primary Contact Person & Phone #:

Emergency Person & Phone #:

When was the last time the patient ate?

Is patient on any medications?

Yes

If so, please list the names, doses and last time given?

What surgery is the patient here for and are there any special instructions?

*I have discussed to my satisfaction the health status of my pet listed

above with Gold Coast Center for Veterinary Care.

*I understand in the event my pet’s heart and/or breathing stops (cardiopulmonary arrest), resuscitation efforts according to the advanced directive authorized below will be undertaken by the doctor(s) and/or staff of Gold Coast Center for Veterinary Care.

*I understand the doctor(s) and/or staff will immediately attempt to contact me via telephone at the telephone number(s) provided by me in the event of cardiac and/or respiratory arrest of my pet.

I request the following resuscitation effort(s) be implemented immediately by the doctor(s) and staff of Gold Coast Center for Veterinary Care (CHOOSE ONE):

Untitled multiple choice field

DO NOT RESUSCITATE (DNR) In the event my pet’s heart and/or breathing stops, I request no person shall attempt to resuscitate my pet.

CLOSED-CHEST CARDIOPULMONARY RESUSCITATION (BLS) I request the doctor(s) and staff attempts to resuscitate my pet through utilization of artificial respiration and/or heart compression, as well as administration of various emergency medications and/or fluids as deemed necessary and/or appropriate by the attending veterinarian.

I understand that I assume financial responsibility for all services rendered, and that payment is due upon hospital discharge of the patient.

Signature of Owner:

Signature

Date:

Physical Rehabilitation Authorization:

In order to ensure the health and proper care for all pets staying at our facility, I hereby give permission for Gold Coast Center for Veterinary Care to perform Physical Rehabilitation on my pet.

I also understand that Gold Coast Center for Veterinary Care is not responsible for any medical conditions or illnesses that may become evident in patient while he is here for Physical Rehabilitation.

In the event that such a condition is discovered, either during the exam or while rehabilitation is being performed, I may be contacted at the number indicated below.

I certify that no guarantee or assurance has been made as to the results that may be obtained and I accept the risks of patient treatment without liability to Gold Coast Center for Veterinary Care.

I understand that my signature below gives authorization for the full course of physical therapy required for patient, authorizing from as few as one visit to multiple visits that may be needed for his rehabilitation.

I fully understand that all fees are due upon discharge and I agree to pay those fees. I am aware that I am responsible for all finances, collections, and attorney fees incurred if I do not pay these charges

Photo/Video Release Form:

Gold Coast Center for Veterinary Care is asking for your consent to take photos/videos and possibly write about your pet’s story on our social media web pages, websites, and in our marketing.

These postings can help to further educate/promote awareness for the many types of treatments, success stories and interesting cases we see here.

*Note- Gold Coast Center for Veterinary Care will never share any of your personal, client information over the internet. (Please check one)

Untitled multiple choice field

I GIVE Gold Coast Center for Veterinary Care permission to take photos/videos and possibly write about my pet’s story, including my pet’s name, on their social media web pages, websites, and possibly in their marketing.

I DO NOT GIVE Gold Coast Center for Veterinary Care permission to take photos/videos and possibly write about my pet’s story, including my pet’s name, on their social media web pages, websites, and possibly in their marketing.

Signature of Owner or Authorized Agent:

Signature