Hospitalization Consent Form

Lots of love will be given to your pet during their stay with us! This form authorizes your pet’s hospitalization and delivery of your approved care for your pet. Please fill this form out completely and accurately.

* Indicates required information

Location*

Pet’s Name*

Primary Contact Name*

First Last

Primary Phone Number*

Secondary Contact Name

First Last

Secondary Phone Number

Reason for Hospitalization:*

Estimate Presented and Signed?*

We will provide an estimate after completing the form.

Hidden

REQUIRES REVIEW

REQUIRES REVIEW
No

Time of most recent meal*

Hour	Minute	AM/PM

List your pet's medications and the last time they were administered.

Medication	Hour	Minute	AM/PM

Any history of drug allergies or anesthetic complications?*

Please explain the complications*

Anything else you’d like us to know about your pet?

Your pet will be monitored and cared for by and under the direct supervision of a veterinarian. Your pet will also be thoroughly and regularly monitored. We will contact you with updates or in the event of an emergency. Feel free to call at any point for an update on your pet and we will happily answer any questions you may have.

In case of life-threatening emergency, and if I cannot be immediately contacted, I authorize my veterinarian and the staff at PAZ Veterinary to*

I hereby consent to and authorize treatment for my pet as deemed medically appropriate in the veterinarian’s professional judgement. I accept financial responsibility for any charges incurred during my pet’s care at your facility, including any emergency care and associated charges. I understand payment is due at the time of my pet’s discharge from the hospital and will render payment in full. Financing is available through ScratchPay during times of financial constraint.

Date*

Signature*

Please only click "Submit" once and do not leave this page! This may take a few seconds.

Email

This field is for validation purposes and should be left unchanged.