Client Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone

Phone Number

Secondary Phone

Phone Number

I would like a text message update of my pet instead of a phone call update

Yes
No

*We may need to contact you with permission to make medical and financial decisions. Please provide the best contacts so we may do so.*

Patient Name

Species

Breed

Sex

Spayed

Neutered

Color

REASON FOR VISIT

Does your pet take part in the following

Does your pet receive a monthly prevention, such as heartworm and flea/tick prevention?

Yes
No

If so what?

Date last given?

Do you need a refill?

Yes
No

When did your pet last eat?

Date

Time

What type of food do you feed your pet?

How much?

Has your pet had any prior history of vaccine or medication reactions?

Is your pet currently up to date with the required yearly vaccinations and physical exam (i.e. Rabies, Distemper Combo, and Bordetella)? If so, please list the date performed.

List ANY medication your pet is currently taking and how often you give the medication

Do you need any refills of these?

Yes
No

which ones?

IF THE VETERINARIANS DEEM IT NECESSARY, I CONSENT TO: (PLEASE CHECK ALL THAT APPLY)

Diagnostic Bloodwork
Urine/Fecal Testing
Radiographs
Sedation/Anesthesia

PLEASE CALL ME BEFORE TREATING IF MY FEE WILL BE OVER $ *

IF LEFT BLANK, WE WILL TREATFOR WHAT WE FEEL IS MEDICALLY NECESSARYFOR YOUR PET.

I certify that I own or represent the owner and hereby authorize the veterinarians at Seymour Animal Hospital to examine, hospitalize,and treat my pet as set forth above or as they deem necessary.I also consent that the Seymour Animal Hospital doctors and staff may administer/perform diagnostic tests, anesthetics, surgical procedures, treatments, vaccinations, and/or medications that the doctors deem necessary for the health, safety, and well-being of my pet while it is under their care and supervision. If my pet should injure itself, refuse food, soil itself, become ill, or die while in the hospital, I will hold the Seymour Animal Hospital free of responsibility and/or liability in the absence of gross negligence. I agree to assume full responsibility for treatment expenses involved and to pay allfeesin full for theservices rendered at the time my pet is discharged from the hospital.If you neglect to pick up your pet that is ready for release within (5) days of a written notice having been mailed to the above address, you may assume that the pet is abandoned and will be authorized to dispose of the animal as see fit. Abandonment does not release me of my obligation for payment of services rendered. I agree that in case of non-payment, a 1.5% per month interest charge will be assessed on accounts not paid within 30 days. In addition, if referral to an outside attorney or collection agency becomes necessary, I willpay a collection fee up to 50% of the balance.

Date

Client Signature

Clear Signature

Date

SAH Staff Signature

Clear Signature

Date

Hospitalization Consent FormSeymour, IN

Hospitalization Consent Form

Ready for your Appointment

Location

Contact Information

Hours

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