CONSENT FORM - SA / LA
OWNER'S NAME:______AGENT'S NAME:______
HOME #______WORK #______CELL# OTHER#______
ADDRESS:______EMAIL ADDRESS:______
PATIENT NAME:______SEX:______AGE:______Patient ID #:______
BREED:______COLOR:______SPECIES:______BRAND/TATTOO: ______
INSURED: Yes_____No_____ INSURANCE INFORMATION: Company Name: ______Insurance #:______
MEDICAL CONDITION/MEDICATIONS?______
I AM THE OWNER OR AGENT FOR THE OWNER OF THE ABOVE DESCRIBED ANIMAL AND HAVE THE AUTHORITY TO EXECUTE THIS CONSENT. I HEREBY AUTHORIZE PAYMENT AND CONSENT FOR THE FOLLOWING PROCEDURE(S) OR OPERATIONS(S):
Estimate of Costs: Deposit: Dr.
I understand that during the performance of the foregoing procedure(s), unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure(s) or operation(s) or different procedure(s) of operation(s) than those set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) or operation(s) as are necessary and desirable in the exercise of the veterinarian's professional judgment.
I also authorize the use of appropriate anesthetics, and other medications, and I understand that hospital support personnel will be employed as deemed necessary by the veterinarian.
I have been advised of the nature of the medication(s), procedures or operations and the risks involved. I realize that results cannot be guaranteed and the procedure(s) may fail to achieve expected results. Risks of anesthesia and surgery include but are not limited to: prolonged sleeping, cardiac arrest, anesthetic death, injury during recovery, fractured bones, myositis, nerve paralysis, bleeding, infection or scarring. I also realize and accept that there is a risk of my animal contracting a nosocomial infection (hospital borne infection) during hospitalization.
COMPLICATIONS MAY OCCUR AND/OR ADDITIONAL TREATMENT MAY BE NEEDED AND COULD RESULT IN EXPENSES THAT EXCEED THE ORIGINAL ESTIMATE.
I HAVE READ AND UNDERSTAND THIS AUTHORIZATION AND CONSENT
Owner or agent:______Date:______
Witness to signature: ______Date:______
CHAPARRAL VETERINARY MEDICAL CENTER POLICY
1. ALL PREVIOUSLY UNPAID BALANCES ARE DUE PRIOR TO RENDERING ADDITIONAL SERVICES. ALL ADDITIONAL FEES ARE DUE AT DISCHARGE & NO CREDIT WILL BE EXTENDED UNLESS PREVIOUSLY APPROVED BY THE PRACTICE ADMINISTRATOR. DEPOSITS ARE REQUIRED FOR HOSPITALIZED PATIENTS AND DETERMINED BASED ON PARTIAL PAYMENT OF ESTIMATED TREATMENT COSTS, DETERMINED BY THE TREATING DOCTORS INITIAL ASSESSMENT (SEE ABOVE ESTIMATE OF COSTS).
2. THERE IS NOTA 24 HOUR OBSERVATION OF HOSPITALIZED PATIENTS UNLESS DEEMED NECESSARY BY THE DOCTOR IN CHARGE. PLEASE ASK IF YOU ARE CONCERNED.
3. VISITING HOURS ARE BETWEEN 9am - 4:30pm MONDAY TO FRIDAY AND 9am - 12pm SATURDAY. VISITS ARE FOR ONE HOUR AT A TIME ON WEEKDAYS AND 1/2 HOUR AT A TIME ON WEEKENDS, UNLESS PRIOR AUTHORIZATION IS GIVEN BY PRACTICE ADMINISTRATOR.
4. WHEN ANIMALS ARE DISCHARGED, OWNER OR AGENT ASSUMES RESPONSIBILITY AND RISKS FOR HOME CARE.
5. FOR PATIENT CONFIDENTIALITY PURPOSES, NO VIDEO, AUDIO, OR PHOTOGRAPHY IS ALLOWED ANYWHERE ON THE PROPERTY WITHOUT EXPLICIT, ADVANCE PERMISSION FROM PRACTICE ADMINISTRATOR.
6. Posting, releasing, or otherwise disclosing photos, identifiable case descriptions, images, or records related to the educational, clinical, or research activities of the Chaparral Veterinary Medical Center, via social networking sites (e.g. Facebook, Twitter, YouTube, blogs etc.) is UNAUTHORIZED WITHOUT ADVANCE PERMISSION FROM PRACTICE ADMINISTRATOR.
OWNER/AGENT INITIALS______
HOSPITAL INVENTORY RELEASE
OWNER'S NAME: ______
PATIENT NAME: ______
DESCRIPTION:______
DATES OF HOSPITALIZATION/TREATMENT - FROM:______TO:______
I AM NOT LEAVING ANY ITEMS WITH MY COMPANION ANIMAL TODAY.
SIGNED:______ DATE:______
EMPLOYEE SIGNATURE:______DATE:______
I AM LEAVING THE FOLLOWING ITEMS WITH MY COMPANION ANIMAL TODAY:
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Office Confidentiality Policy: Chaparral Veterinary Medical Center strives to provide excellent customer service. One way in which we strive to attain this is by keeping all information about your animal confidential. In order to help, we ask that you please do not ask any of the staff to answer any question you may have regarding other in hospital patients. Please list the names of those who you give permission to ask and receive information about your animal.
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______
SIGNED:______DATE:______
EMPLOYEE SIGNATURE:______DATE:______
CHAPARRAL VETERINARY MEDICAL CENTER IS NOT RESPONSIBLE FOR ITEMS LOST OR DAMAGED DURING COMPANION ANIMAL STAY, HOWEVER, WE WILL MAKE EVERY EFFORT TO RETURN YOUR ITEMS IN THE SAME CONDITON THEY WERE RECEIVED.
DIET
MY COMPANION ANIMAL USUALLY EATS THE FOLLOWING DIET, AND I UNDERSTAND THAT UNLESS CHANGES ARE MEDICALLY NECESSARY, THAT IS THE DIET THAT WILL BE FOLLOWED, WITH THE FOOD STOCK AVAILABLE:
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