The Day Admit and Hospitalization Form

Today’s Date

MM slash DD slash YYYY

Owner’s Name(Required)

First

Last

Phone Number(s) where you can be reached TODAY(Required)

Pet's name(Required)

Your Pet’s Age(Required)

Weight(Required)

Is your pet Male or Female?(Required)

Male

Female

Is your pet allergic to anything? If so, please describe:(Required)

Has your pet had any illnesses or seizures in the past? If so, please describe:(Required)

Has your pet been given any food or medications today?(Required)

If your pet needs to be given any medications at home, which to you prefer to give?(Required)

Liquid

Tablets

Requests(Required)

Physical Examination $70-$150

Diagnostics recommended: Bloodwork, etc. $300-$600

Diagnostics recommended: X-Rays, etc. $264-$500

Sedation/Reversal $129-$300

Nail Trim $23+

Anal Gland Expression $25+

Permission(Required)

If we are unable to reach you; you DO give permission for the doctor and team to proceed with above treatments/diagnostics

If we are unable to reach you; you DO NOT give permission for the doctor and team to proceed with above treatments/diagnostics

Consent for treatment:

Owner’s Signature

Admit Nurse Initial

IN THE EVENT OF A MEDICAL CRISIS:

In case of CPR needed:(Required)

I wish for the doctors of the Veterinary Clinic of Myrtle Beach to perform CPR on my pet if he/she suffers respiratory or cardiac arrest. I understand that my pet may or may not respond to this life-saving procedure. I understand that if my pet survives because of CPR, he/she may have permanent health issues. CPR may cost up to or more than $300.00

I DO NOT want CPR performed on my pet. I understand that if my pet stops breathing, and/or his/her heart stops beating, that my pet will die. I elect to have DNR orders placed on my pet’s record for his/her boarding stay.

Owner’s Signature(Required)

Date

MM slash DD slash YYYY

Comments

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