Hospital Admission and Surgery Consent Form in Greeley, CO - Countryside Large Animal Veterinary Services, PLLC

Date*

*Must be at least 18 years of age to complete this form*

Owner Name*

Agent/Leaser Name

Agent/Leaser Phone

Address*

Street Address City State / Province / Region ZIP / Postal Code

Patient Information

Name / Tag #*

Species*

Age / Birthdate*

Breed*

Color*

Sex:*

Male
Female
Altered Male
Altered Female

Feeding Instructions

Belongings Left with Patient

Reason for Hospitalization

Insured?

Yes
No

Insurance Company Name

I do hereby consent and authorize Countryside Large Animal Veterinary Services, PLLC and its staff to hospitalize my animal, and to administer vaccinations, medications, perform tests, surgical procedures, anesthetics, and treatment that the veterinarian(s) deems necessary for the health, safety, and well-being of the above animal while under their care and supervision.

If my animal should injure itself in an escape attempt, refuse food, become ill, or die while in the hospital, I will hold Countryside Large Animal Veterinary Services, PLLC and staff free of any responsibility and/or liability in the absence of gross negligence

If an emergency arises and I cannot be contacted to provide authorization for treatment, the attending veterinarian should act in his or her best judgement. I agree to pay the additional expenses incurred for the emergency treatment.

I have been informed and understand that visitation is during business hours only. Visitation after hours MUST be prearranged with the attending veterinarian. Visiting hours are 9:00am–4:00pm Monday-Friday.

I understand that if I neglect to pick-up the animal within five (5) days of verbal notice that the animal is ready for release, Countryside Large Animal Veterinary Services, PLLC may assume that the animal is abandoned*. Abandonment does not release me from my financial obligations of the bill. *Unless other arrangements have been made

Authorization Treatment / Consent for Surgery

I, as owner or agent for the owner of the animal listed above, have the authority to execute this consent. I authorize Countryside Large Animal Veterinary Services, PLLC to treat and/or perform surgery on the animal listed above. This treatment/procedure may include the use of appropriate diagnostics, medications, anesthetics and/or surgical procedures as deemed necessary in the exercise of the veterinarian’s professional judgement.

Owner Signature*

Date*

Surgery Consent Form

Pre-Anesthetic Blood Work

At Countryside Large Animal Veterinary Services, PLLC pre-anesthetic blood work is required and included in the cost estimate of the surgery for all equine patients. Pre-anesthetic blood work screens the liver, kidney, metabolic and bone marrow functions of your animal. This helps to ensure that your animal will be capable of effectively metabolizing the anesthesia we administer, thereby minimizing the likelihood of any unexpected complications. Your animal’s safety is our highest priority and anesthetic regimens can be altered to fit any particular health concern.

Provision of Pain Relief

Administration of pain medication before some procedures may be warranted. The provision of pain relief is not included in the cost of your animal’s surgical procedure estimate. Pain relief medications post-surgical procedure may also, be necessary.

Please list any diseases, conditions, or medications that your animal is presently being treated for/with. Please list any past conditions we should be aware of:

I understand the risks involved in the medical or surgical procedure to be performed. I understand the risk of injury or death associated with general anesthesia induction, positioning, and recovery. I will not hold Countryside Large Animal Veterinary Services, PLLC liable for any unforeseen complications while Gold Standard Care is provided during the period of hospitalization.

I understand fees are to be paid in full at the time services are rendered, or upon discharge of my animal. If insurance covers this procedure, it will be insurance reimbursed. I have been informed of the cost estimate for the proposed diagnostic and treatment procedures. I further agree that in the case of non-payment, a finance charge of 1.75% per month will be charged and that any collection fees or attorney fees will be paid by me.

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