Hospitalization Consent Form

Primary Owner Name *

First

Last

Patient Name *

Daytime Phone Number *

Can we text you at this number? *

Yes
No
Do not text me

We may text you updates about your pet or when your pet is ready for pick-up.

Medical History *

Please briefly describe the signs of illness your pet is currently showing and when they first developed. List any medications your pet is currently taking and when last recieved.

Treatment Plan *

Call me prior to any treatment or diagnostics with a cost estimate.
Call me prior to any treatment or diagnostics that were not pre-discussed at check-in.
Continue with any necessary treatment and/or diagnostic tests (i.e. blood work, x-rays, etc.).

Please select one of the following.

By typing my name below, I give permission to The Bird & Exotic Clinic to care for my pet during my absence. I understand it is my responsibility to make myself available to discuss my animal’s health while they receive treatment. If I am unable to be reached to authorize life-saving or humane treatments for my animal, it is the right of the doctor to proceed with such treatment until I can be reached. I understand that I will be responsible for paying for such services. *

First

Last

I understand full payment is expected at time of pick-up. If I pick-up my pet after 5:30pm, I understand a $25 late fee will be charged.