|Hospital Admission Form|
Agreement for Hospital Admission and Treatment
(hereafter "the Hospital)
and_________________________________, Owner (or Authorized Agent of:
Authorization For Treatment
As owner (or authorized agent of the owner) of the animal described above, I authorize the Hospital to perform any and all examinations, diagnostic tests, X-rays, and medical and surgical treatment, including the administration of anesthesia, as are determined to be necessary in the judgment of the licensed veterinarian supervising the care and treatment of the animal.
Explanation of Treatment
I have discussed the probable consequences of not providing the animal with certain medical or surgical treatment, and do not wish the following treatment or procedures to be performed:
Retrieval of Animal
I agree to retrieve the animal from the Hospital as soon as the animal is ready for release, upon notification from the Hospital. I agree to be responsible for any fees incurred as a result of a delay in retrieving the animal after receiving such notification. Failure to retrieve the animal shall result in the animal being declared abandoned, whereupon, it may be disposed of in accordance with the applicable provisions of the New York Agriculture and Markets.
Removal of Animal Upon Death
In the event the animal dies while in the Hospital, I agree to remove the animal within twenty-four (24) hours of telephone notification or four (4) days of notification by mail, or to authorize the Hospital to dispose of the animal and give authorization for the type of disposal I wish. Should I fail to give authorization for specific disposal, I understand that the animal will be disposed of by the practice most commonly employed the hospital.
Release From Liability
I hereby release the veterinarians, veterinary technicians, other health professionals, the Hospital and its agents and employees from liability, and waive all claims against each one of them for any and all loss, death or injury to the animal while the animal is in the Hospital.
I have discussed the estimated costs for the services anticipated to be rendered with an agent of the Hospital. I have been notified that I can receive a written fee estimate if I request one. I understand that a final fee will be based on actual services rendered, and agree to pay the full amount at the time of the animal’s release from the Hospital, including any boarding fees. In the event of the animal’s death, I agree to be responsible for the cost of authorized disposal in addition to the cost of medical services. Should the Hospital have to institute collection proceedings to recover any amount owed by me, I agree to pay all costs of such collection proceedings, including any legal fees incurred.
Signature of Owner or Authorized Agent___________________________________________________
Telephone Where I Can Be Reached_________________________________________________
Signature of Admitting Veterinarian______________________________________________
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