Drop Off/Hospitalization Consent Form Client's Name First Last Pet's NameVomiting Yes No# of timesDate StartedDiarrhea Yes NoDate StartedCoughing Yes NoDate StartedSneezing Yes NoDate StartedLoss of Appetite Yes NoDate StartedStraining to Urinate Yes NoDate StartedBlood In Urine Yes NoDate StartedLethargy Yes NoDate StartedIncreased Thirst Yes NoDate StartedIncreased Urine Yes NoDate StartedOther signsHas your pet ever had this before? Yes NoIf yes, then what was the diagnosis and therapyDoes the doctor have permission to run Diagnostic Tests X-raysDoes the doctor have permission to initiate treatment before talking to you? Yes NoCONSENT FOR ADMISSION TO HOSPITALI am the owner or agent for the owner of the animal(s) described on this form and have the authority to execute this consent. I request that the veterinarians, agents and employees of Colonial Animal Hospital perform the services which are necessary to the examination, medication and treatment of the animals specifically described and identified on this form. I authorize the veterinarians on duty (and the assistants they designate) to examine the animal(s) and to administer medical treatment or emergency surgical treatment which is considered therapeutically and/or diagnostically necessary on the basis of the findings during the course of the examination. Therefore, I hereby consent to and authorize the performance of such procedure(s) as are necessary and desirable in the exercise of the veterinarian’s professional judgment. I further understand that any animal found to be infected with either external or internal parasites will be treated for same at my expense. I understand that the treatment of the patient will be conducted with due care and in accordance with the prevailing standards of competency in Veterinary Medicine. I certify that no guarantee or assurance has been made as to the results that may be obtained through the course of treatment undertaken by the veterinarians, agent or employees of Colonial Animal Hospital. I assume financial responsibility for all charges incurred to the patient for services rendered and understand that full payment is required upon discharge. In case of non-payment, I am aware that Colonial Animal Hospital will charge the cost of collecting the debt on the amount owed for services. This includes the collections company’s charges, attorney’s fees and interest of 1.5 % per month (18% annum). I understand that a written estimate of charges is available within reasonable time at my request. I also consent to the release of medical information.SignatureDate MM slash DD slash YYYY Daytime contact phoneHome phoneMust be available at all timesCAPTCHAΔ