VETERINARY MEDICAL ASSOCIATES, INC.
HOSPITALIZATION AND SURGICAL RELEASE FORM
PATIENT NAME_______________________ OWNER_______________________________________________
HOSPITALIZATION/DIAGNOSTICS/RELATED MEDICAL PROCEDURES
Diagnostics and Treatment Specific Procedures_______________________________________
ESTIMATE $_________________________________ to $_________________________________
For time period thru______________________________
(If hospitalization is necessary beyond the above date, a consult with the attending veterinarian should be done at that time to receive an estimate for the continued medical care.)
SURGICAL/DENTAL PROCEDURE____________________________________________________________
ESTIMATE $_____________________ to $_____________________ See Estimate
The preanesthetic protocol necessary prior to anesthesia is explained on the reverse side of this form and is a part of the estimate.
All animals entering the hospital must be up to date on vaccinations and required laboratory tests. All animals must be free of external/internal parasites. Vaccinations, required laboratory tests, and/or treatment for external/internal parasites will be at the client's expense.
VACCINATIONS DUE________________________________________________________________________________________-
LABORATORY TESTS REQUIRED__________________________________________________________________________-
I certify that I own the described patient and do hereby consent and authorize the Veterinary Medical Associates, Inc. and its staff to hospitalize my pet; to administer vaccinations, medications, and anesthesia; and to perform tests, surgical procedures, or treatments that the doctors deem necessary for the health, safety, or well-being of my pet while it is under their care and supervision.
In the event that emergency treatment is required and I cannot be reached, I authorize the Veterinary Medical Associates, Inc. to perform medical and/or surgical treatment necessary to preserve the life of the patient until I can be contacted for further authorization.
I accept financial responsibility for the services provided. I further understand that payment in full is due upon release of the patient from the hospital or upon termination of services.
I hereby certify that I have read and fully understand the authorization for medical and/or surgical treatment; I understand the reason for and the risks involved with the medical and/or surgical treatment; and I have discussed any questions or concerns with the doctor.
SIGNATURE____________________________________________________ DATE___________________________________
CONTACT PHONE #____________________________________________
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