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Drop-Off Consent Form

Please fill out the following regarding your pet you are dropping off

Owner Information

First name

Last Name

Address

City

State

Zip Code

Phone number

Secondary phone number

Email

Patient Information

Pet Name

Species

Color

Breed

Age/DOB

Sex

Drop-Off Information

Where can you be reached throughout the day?

Reason for Visit

If medication is sent home, which do you prefer?

Pills

Liquid

Please check one of the following

Please examine my pet and call me with an estimate prior to any treatments or diagnostics.

Please examine my pet and continue with any necessary treatments or diagnostics.

Emergency Treatment Authorization

If your pet is in critical condition and immediate treatment is needed, the initial stabilization period can cost $200 - $1000. This may include IV catheters, fluid, medications, x-rays, or other tests needed to assess your pet's condition. The doctor will talk to you about further treatment once your pet is more stable.

Emergency Treatment Authorization:

Yes, I authorize the doctor to perform the needed emergency care.

No, I do not authorize such care and need to speak with the doctor before treatment is performed. I understand that the delay in treatment may further endanger my pet's life.

Initial Here to Confirm Treatment Authorization:

CPR Authorization

*If a CPR choice is not marked, basic CPR will be initiated. One CPR is started, we will make reasonable efforts to contact you a responsible party. In the event you or a responsible party cannot be contacted, CPR may be discontinued if patient is not responding to efforts.

CPR Authorization:

No resuscitative efforts (DNR)

Basic CPR (Chest compressions, assisted breathing, medications)

Initial Here to Confirm CPR Authorization Decision:

Medical Consent

By submitting this form, I consent and understand the following: I consent to have my pet treated at Lange Animal Hospital. The preliminary diagnostic and therapeutic plans will be discussed with me along with the potential risks and costs. I understand that no guarantee has been made as to result or cure. I agree to be available by phone at all times during my pet's hospitalization for consultation with my pet's doctor(s). In the event that I cannot be reached, I authorize the doctors and staff to perform any procedures necessary for my pet's wellbeing. I agree to assume all financial responsibility for treatments done to my pet. I understand that final fees can be considerably different than an initial estimate. I understand that I can ask for an estimate at all times, and that I will be notified if any additional treatments or procedures need to be performed on Bella. I understand that billing is not available, and agree to pay the balance of all charges in full at discharge.

I, the above signed owner, agent of the owner, or Good Samaritan responsible for seeking veterinary care for the pet identified, certify that I am eighteen years of age or over.

Client Signature

Signature