TestingClient Name:Pet Name:Date I am the owner (or authorized agent for) of the above-mentioned animal.I have discussed the reasons for hospitalization and I am satisfied with the plan of management. The nature of such services has been described to me to my satisfaction and I realize that neither guarantee nor warranty can ethically or professionally be made regarding the results or cure. I authorize use of sedatives and pain medications if deemed warranted. If anesthesia or sedation is required, I understand, and accept that there are always inherent risks, including death. I also authorize the clinic staff in an emergency situation, to follow through with such procedures as are necessary for the well being of my pet on a continuing basis until further communication with me is possible.I have also had the likely fees explained to me and I have received estimate #ranging from $to $for anticipated medical services. It is understood that there may be unforeseen complications and that further treatment may be necessary during the hospitalization. I accept and assume full and total financial responsibility for any and all services rendered by the clinic, its staff or employees in the treatment of the above described animal and agree to pay the fees at the time of my pet’s discharge or other demise.NameDate Daytime Phone:Home Phone: ——————————————————Client Name:Contact Phone:Agent Name:Agent Phone:Cat’s name:Check-in Date: Check-out Date: Pick-up Time: : HH MM AMPM Please ensure that your designated agent is aware that you have given us his/her name, and is willing and able to make decisions regarding the care and well-being of your cat.Any cat not claimed within ten (10) days of pick-up date, without new provisions being made, will be considered abandoned, and becomes our property and will be handled according to our best judgment.Initial ALL CATS ADMITTED MUST BE CURRENT ON THEIR PHYSICAL EXAMINATION and their vaccinations for FVRCP (Distemper/Upper Respiratory) and Rabies, as well as a Feline Leukemia Virus (FeLV) test. If your cat is past due, your cat will be examined and given the necessary vaccinations or test upon admission, and current charges will apply. THEY MUST BE FREE OF EXTERNAL PARASITES, and cats found to have evidence of parasites will be treated at the owner’s expense. If your cat has special dietary needs or preferences you must provide the food or it may be provided at current charges.Your must bring all medications in their original containers. If medications are not provided, you will be charged at the current rates. Please list any/all medications below, their dosages and instructionsMedication Name Dosage Amount Dosage Instructions Time Last Given? Special Instructions (please initial each line that applies)Unless otherwise instructed your cat will receive Hill’s Science Diet. If your cat has other dietary needs, please provide the food or allow us to provide it at current charges.I have special dietary instructions for my cat. Please specify:I am leaving personal belongings with my cat. Please list: The undersigned hereby warrants that they are the owner or authorized agent for the cat listed in this record and does consent and authorize our staff to care for and treat said cat. If an emergency situation arises, I authorize services, including the use of anesthesia if necessary, to treat my cat until such time as I can be contacted. I understand that every reasonable effort will be made to contact me as soon as possible if an emergency or unanticipated situation arises with my cat. If I am unable to be reached, I authorize the veterinarians to proceed with treatment as deemed necessary for the well being of my cat. I understand I will be responsible for all charges incurred at checkout.If I have requested that medical, surgical, dental, or other services be performed for my cat while it is residing in the boarding kennel, I consent to and authorize our staff to perform diagnostic, therapeutic, anesthetic, emergency, and surgical procedures as are necessary and advisable for the treatment and maintenance of my cat’s health and well-being. I understand that with any procedure or treatment that there are risks that may not be predictable, including death, and I accept these risks. While I expect all procedures to be performed to the best of the abilities of the staff, I acknowledge that no guarantee or warranty regarding the outcome or results of any treatment has been given. I acknowledge that hair may be shaved or clipped as necessary to facilitate treatment. I expect that reasonable precautions will be used to ensure my cat’s safety and well-being while in our care, and I agree to pay in full for all services provided at the time of discharge. I understand that if an unanticipated need for additional procedures or services (e.g. extractions of teeth, biopsies of abnormal tissues, etc.) occurs, a reasonable effort will be made to contact me using the contact information provided above. I understand that if I cannot be contacted, that non-emergency procedures or services will not be performed, at that this may mean that my cat may need to have another procedure at a future date at my expense.Authorized Signature:Date —————————————————–Please fill out everytingName First Last Date Home PhoneCell PhoneWork PhoneEmail Address is used to send out appointment reminders: Physical Address (No PO Box) Street Address City State / Province / Region ZIP / Postal Code Mailing Address (PO Box ok) Check if Same as Physical Address Street Address City State / Province / Region ZIP / Postal Code Emergency contact informationName First Last PhoneRelationshipPatient's NameBreedCanineFelineOtherOtherBithday or age:GenderMaleFemaleNeuteredSpayedColor2nd Patient's NameBreedCanineFelineOtherOtherBithday or age:GenderMaleFemaleNeuteredSpayedColorIf you have a family veterinarian other then Evergreen Animal Hospital, I understand treatment records will be forwarded to the named veterinarian and by signing this authorization I hereby give permission for my pets records to be released.Veterinarian NameHospital NameInitials requiredTreatment Authorization And InformationI hereby authorize Evergreen Animal Hospital to perform medical and diagnostic/ surgical procedures on my pet as required for diagnosis and treatment. I understand that I can terminate at any time by contacting the doctors or technicians.SignatureDate I do hereby grant EAH and its assigns representatives the right to use my pet’s photo and images for advertising, facebook, website etc.SignatureDate How did you find us?Referring Friends / VetBuilding SignWebsiteInternetOtherPet Health Insurance name and numberPlease Note: Current Drivers License # is needed for payment by check or credit card. We cannot accept out of state or post dated checks.Initials of staff who verified DL:DL #StateDL Expiration DateFinancial PolicyWe offer Care Credit, an outside lending service, if payment can't be made at time of service. Ask if neededPayment Is Due In Full As Services Are RenderedFor emergency service, a deposit is required in advance based on the treatment plan. Payment may be made by cash, personal check (with proper identification current in state Drivers License) or accepted credit cards. In order to avoid misunderstandings, please let us know if these terms are not satisfactoryInitials requiredIn the rare event payment is not made at the time of service. It is our policy to apply a service charge to the account balances over 30 days old. A billing fee of $2.00 and 1.5% of the outstanding balance will be charged to your account monthly if not paid in full. If applicable you will be responsible for any legal and/or collection agency expenses that may be incurred.Initials requiredReturned checks are subject to penalties under the Colorado Returned Check Law, C.R.S 13-21-109, for additional information on the Colorado Returned Check Law See www.ago.state.co.us/CADC/BadCheckLaw.cfm or call the office of the Attorney General at 303-886-5304.Initials requiredI understand that I, as the owner or agent, am financially responsible for the applicable Evergreen Animal Hospital charges relating to the treatment my pet(s). I have read and agree to the treatment authorization. I have also read and accept the financial policy.SignatureDate Pet Emergencies When The Owner Isn't Available For DirectionEvergreen Animal Hospital will try to contact you as soon as possible if your pet is brought in as an emergency. If I cannot be consulted, I wish for Evergreen Animal Hospital to (Please initial only one). Take care of my pet to the best that EAH can deliver and I will be responsible for all services rendered Only stabilize my animal until I can be consulted. This typically would include oxygen, fluids and pain medication if needed. Hospitalization charges will still apply for all hours my pet is in the care of EAH and I will be responsible for all charges. I don't want my animal cared for if I'm not present. The care giver of my animal will be sent home without service preformed.Pet owner's signature:Date Thank You For Allowing Evergreen Animal Hospital To Provide For Your Pets Health Care Needs —————————————————–Owner Name:Date Patient Name:Contact Phone:Reason for visit:Symptoms/ Problems:Length of Symptoms/Problems:Eating/Drinking NormalYesNoExplain:Explain:Urination/Defecation NormalYesNoExplain:Explain:Activity Level NormalYesNoExplain:Explain:Diet (brand of food):What medications and/or supplements is your pet currently taking?How often are the medications administered?Permission to perform diagnostics if needed? (x-rays/blood work)YesNoCall FirstPlease give any other information that may be helpful in the treatment of your animal:I give Evergreen Animal Hospital, P.C. authorization to perform treatment as deemed necessary for the health of my pet. SignatureDate The client has indicated by telephone that Evergreen Animal Hospital, P.C. is authorized to perform diagnostic tests and treatment as necessary for the health of their pet.Doctor/TechnicianDate Medical BoardingOwner's namePet's nameDate Emergency phone numberSecond Emergency contactIn the event you can not be reached, can your Contacts make Medical Decisions?*YesNoIn the event of an emergency, if the staff at E.A.H is unable to reach you at the emergency numbers, may we begin treatment?*YesNoIn the unlikely event that your pet becomes critically ill and we can not reach you, may we euthanize your pet if he/she is suffering and unable to be helped?*YesNoPlease specify a price range in which we are allowed to treat your pet: $*Credit Card Number and expiration date:*SignatureDate —————————————————–As owner, or agent for the owner, of the animal, I hereby consent for humane euthanasia to be performed. I further authorize the attending veterinarian to care for the remains in accordance with hospital policy (cremation) and my request below. To the best of my knowledge and belief, this animal has not bitten anyone in the ten days preceding this date.Client's Name:Phone #Animal's name:Sex:Color:Age:Wt:Breed:Species:Acct # X-Small 0-20 lb Euthanasia Only Small 21 – 401 Cremation Only Medium 41 – 751b Euthanasia & Cremation Large 76 - 1251b Hair Clipping ready now or the next day X Large 126 - and up Clay Paw (extra charge) ready the next day.CLAY PAWS MUST BE MADE AT TIME OF SERVICE Do Not Save Communal we dispose of ashes on our property Save Ashes Fiber Container (Biodegradable) or Velour Pouch - Blue/ BurgundyUnless otherwise requested remains are returned in a fiber container or velour pouch and should be ready in 10 to 14 days. You will be notified when they are ready for pickup. Special URN (extra charge)Prepayment on all special ordersSpecial Instructions / ArrangementsPayment due at time of service Owner's signature:Date Dr.StaffLog #Remains will be held for 1 year from the date they are ready for pickup unless other arrangements are made in advance. —————————————————–Time collected: (<1 hr.)Dropped off:Refrigerated:YesNoPlease be aware it may take up to 24hours to hear from us with the results.Owner Name:Patient Name:Client NumberPhone Number:Staff InitialsProblem give details: Is this a recheck Urinalysis or fecal:YesNoHave the symptoms been resolved?How long has it been a problem?Straining?YesNoFrequency?IncreasedDecreasedSameBlood?YesNoMucus?YesNoVaginal discharge? ( applies to a female patient with urinary tract symptoms)YesNoIncreased licking of the vulva or prepuce? (applies to female/male with urinary tract symptoms)YesNoIf this is a fecal test, the consistency of the fecal matter: 1. Watery. 2. Cow Pie. 3. Soft Ice CreamIs your pet having accidents in the house?YesNoBrand of Food:Change in food or dietary indiscretion:” Got in the trash etc.”Eating and Drinking normal?YesNoActivity normal?YesNoVomitingYesNoDo you already have a appointmentYesNoOn Any Medication or supplements (including over-the-counter medications/aspirin/other and prescribed medications/supplements)DoseFinished AntibioticsYesNoNA—————————————————–Owner Name:Date Patient:Contact number:T:P:R:MM:CRT:WT:Client ID:Surgical Procedure:Problem/ location:If this is a Mass/Growth Removal, do you authorize EAH to send out a sample for Histopathology:YesNoDiet (Brand and Amount):Last Time Fed:Current medical conditions:Medications and or supplements: (Dosage, how often administered, last dose given, any refills needed, any aspirin given in the last 2 weeks)Please give any other information that may be helpful in the treatment of your animal: (allergies, aggression ...)Extreme Measures: (Please circle choice):DNR (Do Not Resuscitate)CPRI am authorizing Evergreen Animal Hospital to perform the surgical procedure listed in the signed estimate. All of the above information is complete and accurate. SignatureDate —————————————————–Ever green vet Form Please Fill out everythingPlease fill out everythingDate Name First Last Home Phone #Cell Phone #Work Ph #E-Mail Address is used to send out appointment reminders: Physical Address (No PO BOX) Street Address City State / Province / Region ZIP / Postal Code Mailing Address (PO BOX ok) Check if Same as physical address Street Address City State / Province / Region ZIP / Postal Code Emergency contact informationName First Last Phone #Relationship:Patient's name:CanineFelineOtherBreedBirthday or age:MaleNeuteredFemaleSpayedColor :2nd Patient's name:CanineFelineOtherBreedBirthday or age:MaleNeuteredFemaleSpayedColor :If you have a family veterinarian other than Evergreen Animal Hospital, I understand treatment records will be forwarded to the named veterinarian and by signing this authorization I hereby give permission for my pets records to be released.Veterinarian nameHospital nameInitials requiredTreatment Authorization & InformationI hereby authorize Evergreen Animal Hospital to perform medical and diagnostic/surgical procedures on my pet as required for diagnosis and treatment. I understand that I can terminate treatment at any time by contacting the doctors or technicians.SignatureDate I do hereby grant EAH and its assigns representatives the right to use my pet's photo and images for advertising, facebook, website etc. Signature:Date How did you find us?Referring Friend/VetBuilding SignWeb SiteInternet:OtherPet Health Insurance name and number PLEASE NOTE: Current Drivers License # is needed for payment by check or credit card. We cannot accept out of state or post dated checks.Initials of Staff who Verified DL:DL #StateDL expiration DateFinancial PolicyWe offer Care Credit, an outside lending service, if payment can't be made at time of service. Ask if neededPayment Is Due In Full As Services Are Rendered.For emergency service, a deposit is required in advance based on the treatment plan. Payment may be made by cash, personal check (with proper identification current in state Drivers License) or accepted credit cards. In order to avoid misunderstandings, please let us know if these terms are not satisfactory. * Initials requiredIn the rare event payment is not made at the time of service. It is our policy to apply a service charge to the account balances over 30 days old. A billing fee of $2.00 and 1.5% of the outstanding balance will be charged to your account monthly if not paid in full. If applicable you will be responsible for any legal and/or collection agency expenses that may be incurred. * Initials requiredReturned checks are subject to penalties under the Colorado Returned Check Law, C.R.S 13-21-109, for additional information on the Colorado Returned Check Law See www.ago.state.co.us/CADC/BadCheckLaw.cfm or call the office of the Attorney General at 303-886-5304. * Initials RequiredI understand that I, as the owner or agent, am financially responsible for the applicable Evergreen Animal Hospital charges relating to the treatment my pet(s). I have read and agree to the treatment authorization. I have also read and accept the financial policy. SignatureDate Pet Emergencies When The Owner Isn't Available For DirectionEvergreen Animal Hospital will try to contact you as soon as possible if your pet is brought in as an emergency. If I cannot be consulted, I wish for Evergreen Animal Hospital to (Please initial only one). Take care of my pet to the best that EAH can deliver and I will be responsible for all services rendered Only stabilize my animal until I can be consulted. This typically would include oxygen, fluids and pain medication if needed. Hospitalization charges will still apply for all hours my pet is in the care of EAH and I will be responsible for all charges. I don't want my animal cared for if I'm not present. The care giver of my animal will be sent home without service preformed.Pet owner's signature:Photo/Video Model Release* I AgreeI do hereby grant Evergreen Animal Hospital and its assigns, licensees, and legal representatives the irrevocable right to use my and my pet(s) photograph/image for advertising, or any lawful purpose, and I waive my right to inspect or approve the product.Date Thank You For Allowing Evergreen Animal Hospital To Provide For Your Pets Health Care Needs