Patient Admission Form

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Patient Admission Form

So that we can prepare for your arrival, please complete and submit this form before your scheduled appointment time.

Printable Version

Name *

First

Last

Email *

Cat's Name *

Contact Information

Phone number where I can be reached on the day of my cat's visit: *

Preferred method of contact: *

Text
Phone Call

Emergency Contact: Please provide the name and phone number of a person authorized to make medical decisions on your behalf in the event that we cannot reach you at the phone number listed above.

Emergency Contact Name *

First

Last

Phone Number *

Please read the following statements, then sign below.

I have been advised of the nature of the services and procedures included in the Treatment Plan, as well as the risks involved. While I expect all procedures to be performed to the best of the staff’s abilities, I realize that medical results cannot be guaranteed. *

I have read and agree

In the event of an emergency, the doctor and/or her agent will attempt to contact me at the phone number listed above. If they cannot reach me, I would like the doctor and/or her agents to do the following (choose ONE): *

Perform any additional diagnostic or therapeutic procedures necessary to treat my cat and maintain my cat’s health and comfort. I expect the doctor and/or her agents to use reasonable precautions to ensure my cat’s safety, and I agree to pay in full for all services provided when my cat is discharged.
I do not authorize any additional diagnostic or therapeutic procedures beyond what is stated in the Treatment Plan. I understand that delaying necessary treatment could be harmful to my pet.

I have reviewed and approved the Treatment Plan presented to me. I understand that a deposit of 100% of the lower end of the estimate is due when my cat is admitted to the hospital, and that the remainder of the invoice is due in full at discharge. I understand that the estimate may not be a complete representation of my final bill if additional procedures are performed. *

I have read and agree.

Signature *

Date *