Hospital Authorization Form

Hospital Authorization Form

This form is to be used for any pet that will be hospitalized with us for a medical procedure.

Client's Name
Primary Contact: Who can we contact during your pet's stay with us?
Secondary Contact

Does your pet have any known allergies or any adverse reactions to medications or anesthesia?(Required)
Does your pet have any known medical conditions?(Required)
Has any aspirin or other over-the-counter medications been given to your pet in the past two weeks?(Required)
Is your pet currently on any medications?(Required)
Including heartworm, flea and tick preventatives.
Has your pet been tested for heartworm/FeLV/FIV in the past 12 months?(Required)
Do you want your pet to be microchipped while he/she is with us?(Required)
Does your pet need any additional procedures while he/she is with us?(Required)
If your pet coming in for surgery for a lump/mass removal?(Required)

Post Operative Collars: For surgery patients

If applicable, your pet will go home wearing a post surgical collar (e-collar)to deter him/her from licking or biting at the suture or incision area. The cost of this collar has been factored into your pet’s treatment plan.

Your choice:(Required)
It is crucial to keep this protective collar on at all times to avoid infection, swelling, and interference with the healing process. If your pet gains access to the surgical site, please contact Plummer Pet Hospital immediately to determine if an earlier visit is necessary. At the recheck, we will assess if it is safe to remove the surgical protection.
Consent

Is your pet coming in for a dental procedure?(Required)

Resuscitation Order

Should some unexpected life-saving emergency or immediate care be required and the attending veterinarian is unable to reach me, this practice’s staff has my permission to provide such treatment and I agree to pay for all related fees.

Please choose below:(Required)

Authorization: Please read, consent and sign below.

I, the undersigned owner or authorized agent of the owner, certify that I am over eighteen years of age and hereby consent and authorize Plummer Pet Hospital to perform the above described procedures and services. Furthermore, I agree that after consultation with me, the hospital’s doctors may prescribe medications for, treat, hospitalize, sedate, anesthetize and or perform surgery of this animal.

If my pet needs anesthesia/surgery: I acknowledge that I have been informed of the potential risks associated with surgery and anesthesia. At Plummer Pet Hospital, we take every precaution to prevent complications through pre-surgical exams and bloodwork. Despite these measures, post-operative complications such as infection, swelling, lethargy, and variable recovery times can occur, and in rare cases, may result in death. I understand that each animal's response to surgery can differ based on the condition's involvement and individual factors. I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure is initiated.

I further agree that either I, or an authorized agent of mine, will drop-off and/or pick-up this pet and pay for all accrued charges when my pet is discharged from Plummer Pet Hospital. I assume full financial responsibility for all expenses involved. Our payment options are Cash, Personal Check, Debit, Visa, MasterCard, American Express, Discover, All Pet Card, ScratchPay, Cherry, or CareCredit.

Digital Signature(Required)

Important:

Once you click Submit, you will see a message that says your form was successfully submitted. If you do not, please scroll the form for missing information.