Hospitalization Consent Form

Owner's Address:(Required)

Pet's Species(Required)

Please check the symptoms below that apply to your pet:(Required)

Does the doctor have permission to run diagnostic tests, if needed?(Required)

Does the doctor have permission to initiate treatment before talking to you?(Required)

Consent For Admission To The Hospital

I am the owner, or agent for the owner, of the animal described on this form and have the authority to execute this consent. I request that the veterinarian(s), agents and employees of North Texas Veterinary Clinic perform the services which are necessary to the examination, medication, and treatment of the animals specifically described and identified on this form.I authorize the veterinarian(s) on duty, and the assistants they designate, to examine the animal and to administer medical treatment or examination. Therefore, I hereby consent to and authorize the performance of such procedures as are necessary and desirable in the exercise of the veterinarian’s professional judgment.

I further understand that any animal found to be infected with either external or internal parasites will be treated for same at my expense. I understand that the treatment of the patient will be conducted with due care and in accordance with the prevailing standards of competency in Veterinary Medicine. I certify that no guarantee or assurance has been made as to the results that may be obtained through the course of treatment undertaken by the veterinarian(s), agents, or employees of North Texas Veterinary Clinic.

I am aware that North Texas Veterinary Clinic is not a 24-hour facility. I understand that veterinary services may be provided during the late evening hours as the veterinarian in charge sees necessary, however, I am aware that 24-hour presence of qualified personnel will not be provided by the hospital.

I assume financial responsibility for all charges incurred to the patient for services rendered and understand that full payment is required upon discharge. I also understand that I may be required to provide a deposit at drop-off based on the initial assessment of the patient. In case of non-payment, I am aware that North Texas Veterinary Clinic will charge the cost of collecting the debt on the amount owed for services. This includes the collections company’s charges, attorney’s fees and interest of 1.5% per month (18% annum.).

I understand that a written estimate of charges is available within reasonable time at my request. I also consent to the release of medical information.

By signing below you agree to all of the above.

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