Hospital Admission Form

Patient Information

Pet's Name*

Please list any belongings staying with your pet

Is your pet currently on any medications?*

Yes
No

Medications: Please list medication name, dosage, and last date/time administered:*

Diet/Feeding Instructions*

Please list any allergies

Client Information

Owner's Name*

First Last

How would you like to be contacted today?

Call
Text

Phone Number*

Emergency Contact Name*

First Last

Emergency Contact Phone Number*

Informed Consent

I am the owner/agent for the owner of the animal described and have the authority to execute this consent.
I have been advised of and understand the nature and risks associated with the procedure(s) to be performed and my questions regarding the procedure(s) have been answered to my satisfaction.
I certify that no guarantee or assurance has been made as to the results that may be obtained through the course of treatment undertaken by the veterinarians or employees of The Small Animal Clinic at Piedmont Equine.
I will not hold The Small Animal Clinic at Piedmont Equine liable for any unforeseen complications while treatment is being conducted in accordance with the prevailing standards of care in veterinary medicine.
I assume financial responsibility for all charges incurred to the patient for services rendered and understand that full payment is required upon discharge.
I have read and understand this authorization and consent.

I hereby consent to and authorize the performance of the following procedure(s):*

Should a medical emergency arise while my pet is in the care of the staff of The Small Animal Clinic at Piedmont Equine, and I or my emergency contact cannot be reached to provide authorization for treatment, the attending veterinarian will proceed to stabilize my pet in a conservative, reasonable manner according to their professional judgement. (Please check one of the following.)*

I authorize emergency treatment if required and agree to pay any additional expenses incurred for such treatment.
I do NOT approve any additional emergency treatment.

Name*

First Middle Last

Date*

Monday	8:00am – 6:00pm
Tuesday	8:00am – 6:00pm
Wednesday	8:00am – 6:00pm
Thursday	8:00am – 6:00pm
Friday	8:00am – 6:00pm
Saturday	8:00am – 12:30pm
Sunday	Closed

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Hospital Admission Form

Patient Information

Client Information

Informed Consent

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Pet Health

Hospital Admission Form

Patient Information

Client Information

Informed Consent

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Pet Health