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info@familypethealth.com
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Day Admission
Please fill out this form electronically prior to your visit.
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Date
Person Responsible for Care Decisions
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First
Last
Email
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Best number today to reach the person responsible for care decisions
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Pet's Name
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Reason for visit:
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We are so glad you have decided to entrust your pet to us. We follow the Fear Free approach for all of our patients.
Because you know your pet better than anyone, we need your help to make his or her visit Fear Free!
Please describe the items you are sending with your pet for the appointment.
What medications/supplements is your pet taking?
Any vomiting/diarrhea or coughing/sneezing? If so, please explain.
We want your pet to feel safe and secure in our care. If our veterinarians determine that your pet is concerned or worried and is unable to relax during the visit, they may review its medical record and consider prescribing dietary supplements or medication to help decrease fear and anxiety.
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I have read and understand.
I understand that if at anytime during my pet's visit with Family Pet Health fleas are found, a Capstar pill will be administered for an additional $15.00. By signing below, I agree to the Capstar administration and understand that I am responsible for the fees.
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I have read and understand.
I understand that my pet must be current on all vaccinations and testing in order to be kept at Family Pet Health, by signing below, I agree to the necessary vaccinations and testing to make my pet comply to Family Pet Health standards.
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I have read and understand.
I understand that Family Pet Health is a teaching hospital and that my pet may be treated by a veterinary student under the supervision of a licensed veterinary professional. I will share any concerns about the teaching arrangement with the supervising veterinarian.
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I have read and understand.
In the event that your pet were to experience a cardiac or respiratory arrest (no longer have a heartbeat or stop breathing), our standard procedure would be to initiate Cardiopulmonary Resuscitation (CPR). Please note that costs of this can range from $250-$500 depending on the nature and duration of intervention. As a pet owner, you may prefer to not have resuscitation performed. In such cases, you have the option to elect a Do Not Resuscitate (DNR) order.
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Yes. If necessary, I wish to have CPR performed on my pet.
No, thank you. If my pet passes away, please do NOT resuscitate him/her.
By signing below I agree that I have had the opportunity to ask questions regarding what will be done to my pet during its visit. My questions have been answered and I assume all financial responsibility incurred during the visit.
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I have read and understand.
Signature
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Clear Signature
I am the owner or the authorized agent for the owner of the animal described above, and I have the authority to execute this consent. My signature above certifies that I am over eighteen years of age.
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