Hospitalization Authorization

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

Pet's Name(Required)

Species:(Required)

Sex:(Required)

Color:(Required)

Markings:(Required)

Age:(Required)

I, the undersigned owner, authorized agent of the owner of Good Samaritan responsible for seeking veterinary care for the pet identified, hereby consent to the examination of this pet by staff veterinarians at this veterinary practice. I also agree that after consultation with me, the hospital's doctors may prescribe medication for, treat, hospitalize, sedate, anesthetize, and/or perform surgery on this animal. I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure is initiated. Should some unexpected life-saving emergency care be required and the attending veterinarian be unable to reach me, this practice's staff has my permission to provide such treatment and I agree to pay for all related fees. I accept that veterinary medicine is an inexact science and that no guarantee of successful treatment has been made.(Required)

I certify I AM over eighteen years of age.

I certify I AM NOT over eighteen years of age.

I understand that an estimate of the costs for veterinary services will be provided to me and that I am encouraged to discuss all fees attendant to such care before services are rendered and during this pet's ongoing medical treatment. If this animal is hospitalized, I agree to pay a deposit of the estimated fees and assume financial responsibility for the balance of all services rendered on a cash, credit card, or check basis at the time the pet is discharged from the hospital. In the event the pet is hospitalized for more than twenty-four hours and the attending doctor is unable to reach me, I understand it is my responsibility to call the hospital at least every twenty-four hours to inquire as to the medical status of my pet and the fees incurred for medical services up to that day.

Deposit Amount(Required)

I further agree that either I, or an authorized agent of mine, will pick up this pet and pay for all accrued charges within 2 days after receiving written or oral notification that this animal is ready to be released from the hospital. Such notice will be given at the address maintained on the hospital's patient/client record. I agree that if I fail to comply with this policy, this practice may handle this abandonment in the best interests of the pet and the hospital and I will be responsible for all fees incurred.(Required)

I agree to the statement above.

Procedures to be performed:

Signature(Required)

Hospitalization Authorization

Contact Us

About Us