Hospital Admission Form

Client Information

Owner's Name*

First Last

Farm Name

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone*

Employer

Work Phone

Cell Phone

Email*

Procedure Date*

Procedure Time*

Doctor*

Patient Information

Name*

Age*

Breed*

Color*

Sex*

Insured

Referral Information

Referring Doctor

Referring Practice

Contact Number

Email Address

Fax Number

Emergency Contact

Name*

First Last

Phone*

1. I hereby authorize the performance of the following procedure(s)
2.I understand the risks involved in the medical or surgical procedure to be performed. I understand the risk of injury or death associated with general anestesia induction, positioning, and recovery. I will no hold Piedmont Equine Practice liable for any unforeseen complications while standard of care is provided during the period of hospitalization.
3. If an emergency situation arises, and I cannot be contacted to provide authorization for treatment; the attending clinician should act in his or her best judgement. I agree to pay the additional expenses incurred for the emergency treatment.
4. I have been informed and understand that visitation is during business hours only. Visitation after hours MUST be pre-arranged with the attending clinician.
5. I understand fees are to be paid in full at the time services are rendered. I have been informed of the cost estimate for the proposed diagnostic and treatment procedures. I agree to leave a deposit for half of the average estimate at this time, and pay the balance of the cost in full upon discharge of my animal. If the estimate is increased, I agree to pay an additional deposit.
6. I understand PEP will give an update of fees verbally or by email each business day.

I, the owner or authorizing agent of the patient and procedure described above, assume full financial responsibility for all charges regardless of the outcome of the patient's treatment.

*Horses will not be discharged from the hospital until all paperwork and payment arrangements have been completed and signed. Any additional charges incurred during this are the owner's responsibility to pay.

Please sign by entering your name*

First Last

and enter today's date*

Monday	8:00am – 5:00pm
Tuesday	8:00am – 5:00pm
Wednesday	8:00am – 5:00pm
Thursday	8:00am – 5:00pm
Friday	8:00am – 5:00pm
Saturday	Closed
Sunday	Closed

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Hospital Admission Form