Drop-Off Form In effort to ensure that we are communicating examination findings, treatment recommendations, and obtaining authorization for services from the responsible party for your pet's care, please complete the below:Please choose from the following: I am the responsible party for decisions and payment. My best contact information is listed below. I am NOT the responsible party for decisions and payment. The best contact information for the responsible party is listed below. Client Name(Required)Patient Name(Required)Best Contact Number(Required)Date MM slash DD slash YYYY How should we contact you? Text Call Being responsible for the above-described animal, I have the authority to grant you my consent to receive, prescribe for, treat and/or operate on my pet. I authorize the personnel of Rolesville Veterinary Hospital to:Perform bloodwork as recommended for my pet. (estimated cost is $308) Accept Decline Give medication in the hospital and prescribe for home use if needed for my pet. Accept Decline Use fluid therapy for my pet if needed as determined by the doctor. Accept Decline Update annual vaccinations or recommended diagnostic test; e.g. heartworm, medication rechecks, Feline Leukemia testing. Accept Decline What do you feed your pet and when was he/she last fed?Please list the reasons why we are seeing your pet today, and any concerns you may have.List of current medications your pet is taking.Are there any additional concerns you would like for us to address during this visit today?I understand that Rolesville Veterinary Hospital is not staffed overnight and I accept any risks incurred by leaving my animal overnight unattended. I understand that I have the option to transport my animal to an overnight/24-hour facility if I so desire. Accept I understand a written estimate for these services will be made available upon my request and that I will provide a 50% deposit for the estimated fees. Accept In an effort to maintain a flea-free hospital, if fleas are found on my pet upon admittance to Rolesville Veterinary Hospital, I agree to treatment with an appropriate oral or topical flea treatment to prevent spread of those parasite to other hospitalized patients. I understand I will be charged for this treatment. Accept I understand that Rolesville Veterinary Hospital is not responsible for personal belongings that are left with your pet. We do provide towels and blankets in the cages where all patients are kept. Accept While I accept that all procedures will be performed to the best of the abilities of the hospital's staff, I understand that no guarantee has been made regarding the results that may be achieved. I agree to assume financial responsibility and provide payment at the time that services are rendered. Accept General Information on CPR Consent/Decline Directive for Cardiopulmonary Resuscitation and Release of Legal LiabilityShould, based on the medical judgement of an Animal Diagnostic Veterinarian, my pet require cardiopulmonary resuscitation (CPR) including cardiac compression, positive pressure respiration, emergency drugs, or other heroic interventions, I request or decline that the doctor(s) at Rolesville Veterinary Hospital pursue such medical care as indicated below. REQUEST CPRRequest for CPR: Having requested such emergency procedures, I agree to be held responsible for a minimum resuscitation fee of $190.00 to pay for the services performed while staff members pursue treatment and try to reach me for further directions. Regardless of my pet's survival, I agree to pay this fee in addition to the other fees already identified by the practice and agreed upon by me. I agree that if the Rolesville Veterinary Hospital staff is unable to reach me within 15 minutes after the initiation of CPR procedures, and after exercising reasonable medical judgement, a veterinarian determines that there appears to be virtually no hope for medical success, the future CPR procedures will cease. I have been informed by Rolesville Veterinary Hospital and understand that despite the best efforts of the veterinarian and staff at Rolesville Veterinary Hospital, CPR may not save my pet's life. I also understand that even the most successful CPR that restores my pet's life may not allow my pet to regain his/her normal mental and physical health, and thus, may leave him/her as an invalid. I request CPR. DECLINE CPRDO NOT RESUSCITATE MY PET. I have read the above information and release. I agree to the above terms and request that NO CPR BE PERFORMED ON MY PET. I decline CPR. Electronic Signature(Required)Owner/Responsible PartyBest Contact Phone Number(Required)Date(Required) MM slash DD slash YYYY CAPTCHA
