Hospitalization Consent Form PhoneThis field is for validation purposes and should be left unchanged.Lots of love will be given to your pet during their stay with us! This form authorizes your pet’s hospitalization and delivery of your approved care for your pet. Please fill this form out completely and accurately.* Indicates required informationPet’s Name(Required)Primary Contact Name(Required) First Last Primary Phone Number(Required)Secondary Contact Name First Last Secondary Phone NumberReason for Hospitalization:(Required)Estimate Presented and Signed?(Required)Select oneYesNoWe will provide an estimate after completing the form. This field is hidden when viewing the formREQUIRES REVIEW REQUIRES REVIEW No Time of most recent meal(Required)HourMinuteAM/PMList your pet's medications and the last time they were administered.MedicationHourMinuteAM/PM Any history of drug allergies or anesthetic complications?(Required)Select oneYesNoPlease explain the complications(Required)Anything else you’d like us to know about your pet?Your pet will be monitored and cared for by and under the direct supervision of a veterinarian. Your pet will also be thoroughly and regularly monitored. We will contact you with updates or in the event of an emergency. Feel free to call at any point for an update on your pet and we will happily answer any questions you may have.In case of life-threatening emergency, and if I cannot be immediately contacted, I authorize my veterinarian and the staff at PAZ Veterinary to(Required)Select oneProvide any interventions deemed necessary, including, but not limited to, CPRNo CPR, but ensure patient comfort. Euthanize if suffering.Do not resuscitate (DNR)I hereby consent to and authorize treatment for my pet as deemed medically appropriate in the veterinarian’s professional judgement. I accept financial responsibility for any charges incurred during my pet’s care at your facility, including any emergency care and associated charges. I understand payment is due at the time of my pet’s discharge from the hospital and will render payment in full. Financing is available through ScratchPay during times of financial constraint.Date(Required)Signature(Required)Please only click "Submit" once and do not leave this page! This may take a few seconds.
