Inpatient General Form • Animal Hospital of Lake Villa

Name *

First

Last

Email *

Phone *

Pet(s) Name(s) *

I, the undersigned, do hereby certify that I am the owner (or duly authorized agent for the owner) of the animal described above, that I do hereby give Animal Hospital of Lake Villa, its agents, and/or representatives, full and complete authority to perform the surgical/medical procedure discussed.

What Problems Is Your Pet Experiencing? *

Approximately When Did the Issue Begin? *

Since Then, Have the Problems Improved, Stayed the Same, or Gotten Worse? *

Worse
Same
Improved

Has This Happened Before? *

Yes
No

Pet's Normal Mental Status? *

Is Your Pet Having Any Diarrhea or Urinary Accidents? *

Yes
No

If Yes, Please Explain? *

How Is Your Pet's Water Intake? *

Normal
Increased
Decreased
I haven't noticed

When Is the Last Time Your Pet Ate? *

This morning
Last night
More than 1 day ago

Is Your Pet Doing Any of the Following? *

When Was Your Pet's Last Bowel Movement? *

This morning
Yesterday
2-5 days ago
Other

How Is Your Pet's Behavior At Home? *

Normal
Quiet / Lethargic
Other

Is Your Pet On Any Medications Or Supplements? *

Yes
No

If Yes, Which Ones, What Dosage & Were Any Given This Morning? *

Please provide as much information as possible.

Behavioral Intervention *

I understand that if my pet is experiencing fear, stress, or anxiety, that Animal Hospital of Lake Villa may administer a pharmaceutical to help calm the patient before the procedure takes place.

Is Your Pet Up to Date on Vaccines & Preventatives (Heartworm, Flea & Tick Treatments) *

Yes
No
I'm not sure
My pet has only been here, it's in the patient file

Pictures & Texting - May We Text You Status Updates & Pictures of Your Pet? *

Yes, please send status updates, including pictures.
Yes, please send status updates, however I don't need pictures.
No, I do not want to receive status updates or pictures.
Please, call with updates.

May We Use Pictures For Our Own Social Media? *

Yes
No

When Are You Available for Discharge & Release Appointment? *

I further consent to the performance of operations and procedures in addition to or different from those now contemplated, arising from presently unforeseen conditions, which the above-named veterinarian or his associates or assistants may consider necessary or advisable in the course of the operation. I further consent to the administration of such anesthetics as may be considered necessary or advisable by the veterinarian responsible for this service. As my signature below indicates, I understand the nature and purpose of the operation, possible alternative methods of treatment, the risks involved, and the possibility of complications, and I have no further questions. I recognize that the practice of medicine and surgery is not an exact science and acknowledge that no guarantees or assurances have been given to me as to the result of any treatment, medication or procedure given at the hospital.

Payment Options - How Do You Intend to Pay? *

The undersigned also understands that all services are to be paid in total when the pet(s) is/are discharged unless prior arrangements are made. The owner or agent promises to pay such total, together with any other charges, finance and/or collection, due thereon. A written estimate will be furnished upon request. Forms of payment accepted include Cash, Mastercard, Visa, American Express, Discover, Scratchpay, or Care Credit. Personal checks are not accepted as a form of payment.

Signature of Owner *

Date / Time

Date

Time