Date of Day Admission Appointment(Required) MM slash DD slash YYYY Pet’s Name(Required)Owner’s Name(Required) First Last What food do you currently feed, including regular treatsHow frequently and how much do you feed this pet?What is your pet’s heartworm prevention medication and when was the most recent dose given?What is your pet’s flea & tick prevention medication and when was the most recent dose given?Is your pet on any additional medications or supplements on a regular basis? Yes/No(Required) Yes No If yes, please describe medication/supplement name, frequency of administration, and most recent dose(Required)Emergency Care Should unexpected life-saving emergency care be required I would like the hospital staff to attempt life-saving measures:(Required) Yes No consent(Required) I authorize Southwoods Animal Hospital to do whatever is necessary should an anesthetic complication arise, and I accept responsibility for any additional expenses incurred. Vaccination Requirements Initial(Required)I understand that my pet must be current on vaccinations for canines: DHPP, Bordetella, and Rabies (administered by a licensed veterinarian) and felines: FVRCP and Rabies (administered by a licensed veterinarian) to stay in this facility. If my pet is overdue for these vaccines or if I fail to provide proof of vaccination, they will be administered at my expense. Fleas & Tick Policy Initial(Required)I understand that if external parasites are found on my pet that an appropriate treatment will be administered at my expense. TREATMENT CONSENT Initial(Required)I, the undersigned owner, or owner’s agent, of the pet identified above, certify that I am at least 18 years of age, and thereby consent to the examination and treatment of my pet by the veterinarians and staff at SWAH, and after consultation with me to prescribe medication for, treat, hospitalize, anesthetize. TREATMENT EXPLAINATION Please explain the reason(s) for your pet’s visit, including but not limited to scheduled testing, chronic illness, or new problem/ailment(Required)consent(Required) I agree that I, or an agent of mine, will pick up my pet and pay for all accrued charges at the time my pet is discharged. Boarding and treatment charges will accrue for each additional day my pet stays in the facility. If I fail to pick up my pet from SWAH within 5 days of receiving written or oral notification given to the contact information on file that my pet is ready to be released, my pet will be considered as abandoned, and SWAH may handle this abandonment in the best interest of the animal and the hospital. Best Contact Number(Required)Emergency Contact NumberName(Required)Signature(Required) Δ
