Hospitalization / Anesthesia Check-In Form

Day stay / Hospitalization Consent Form

Last name: _________________________

First name(s): ______________________________

Pet name: ________________________

Contact Phone number(s): _______________________

 

Please read and sign below:

  • I authorize the admission of my pet to Pismo Beach Veterinary Clinic for diagnostic procedures, medical treatments, and/or hospitalization.  The phone number above is my best contact during this time.
  • [    ] If checked, your pet is being admitted for a procedure under anesthesia.  To increase the patient’s safety as much as possible, we recommend a screening blood panel to make sure the pet is healthy enough to handle the anesthesia.  This panel tests for dehydration, anemia, diabetes, liver disease, and kidney disease.

 

    • Circle:  I accept / decline the screening blood panel.

 

  • I understand that the doctors and staff will use all reasonable precaution against injury, escape, or death of my pet.  I understand that all anesthesia involves some minimal risk to my pet and I will not hold the doctor and staff responsible under any circumstances. I understand that I assume all risks.
  • I assume full financial responsibility for this animal and agree to pay all charges upon release or as otherwise arranged in advance.

 

Signature: ____________________________

 

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Veterinarian/Owner of Pismo Beach Veterinary Clinic

Posted in Clinic Forms
Contact Us
Work: (805) 773-0474
Fax: (805) 773-5902
990 Price Street
Pismo Beach, CA 93449

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