Hospitalization Form

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)

Sex(Required)

Female

Male

Does your pet have insurance?(Required)

Yes

Who is your insurance provider?(Required)

Is your pet on any medications at this time? If so, please list all medications and frequency given:(Required)

Is your pet given consistent MONTHLY preventative medication? (Heartworm and Flea):(Required)

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

Pills/Table

My pet needs a diagnostic work up for a medical condition and I consent to the following testing:

Physical Examination

Sedation or Anesthesia

Radiographs

Bloodwork and Diagnostic testing

Nail Trim/ Anal Gland Expression (circle)

Vaccinations that are due/overdue

Please provide ANY additional information that will help us diagnose your pet’s problem quickly, efficiently and with the least amount of cost to you as possible

Consent(Required)

All pets that are hospitalized are required to have current vaccinations, and must be free of contagious parasites such as fleas, ticks or gastrointestinal worms. If we are unable to secure proof of vaccinations or notice any parasites that will affect other animals in our care, we will treat your pet for any of these conditions and you will be charged for these services.

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 $300.0

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 sta

Signature(Required)

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