Name *

First

Last

Phone *

Other Phone

**WE MUST BE ABLE TO CONTACT YOU WHILE YOUR PET IS HOSPITALIZED

Email *

Pet's Name *

Species

Male
Female
Spayed
Neutered

Breed

Weight

Age

Main reason for today’s visit: *

Medications your pet is currently taking:

Does your pet chew or ingest items other than food?

Yes
No

Is your pet fed table scraps/human food?

Yes
No

If so, what & how often?

Is your pet exposed to toxic chemicals: anti-freeze, rat poison, cleaning agents, etc.?

Yes
No

If yes, please specify:

Please circle any changes seen at home, and note when you first noticed these changes.

GENERAL ATTITUDE

Bright
Quiet
Depressed
Other

Please explain:

APPETITE

Normal
Increased
Decreased
Not Eating

Food normally given:

First noticed:

DRINKING

Normal
Increased
Decreased
Not Drinking

First noticed:

CHECK ALL THAT APPLY

First noticed:

BOWEL HABITS

First noticed:

URINATION

Changes in litterbox habits:

First noticed:

VOMITING

Blood
Food
Phlegm

Color

Amount:

First noticed:

MOUTH/TEETH/GUMS

Swollen
Drooling
Odor
Blood

First noticed:

EYES

First noticed:

EARS

First noticed:

SKIN

Location:

First noticed:

MUSCULOSKELETAL

Lameness
Painful
Head Tilt
Physical trauma

Location:

First noticed:

ENVIRONMENT

Indoors only
Inside / Outside
Outdoors

PLEASE TAKE A MOMENT TO READ & INITIAL EACH SECTION

*** We MUST be able to reach you WHILE your pet is under anesthesia. If for any reason contact cannot be made at the phone number provided, the veterinarian may perform procedures necessary for the health of the patient.

I understand C.C. Veterinary Hospital cannot guarantee the health of my pet. I understand that anesthesia and surgery always involves some risk (such as unknown internal physical abnormalities, medication allergies, surgical complications, including death, internal bleeding, shock, incision dehiscence, and post-surgical infection), and agree to hold C.C. Veterinary Hospital harmless, in the absence of negligence, in connection with these procedures. I acknowledge that no guarantee or assurance has been made to me as to the results that may be obtained. *

If unforeseen conditions arise which, in the judgment of the attending veterinarian, require procedures and/or treatment other than those authorized in this release, and staff are unable to contact me or my authorized agent at the phone numbers listed above, I assume full responsibility for treatment expenses incurred. *

I understand that if I, the owner or authorized agent, do not contact C.C. Veterinary Hospital regarding the animal noted on this release after 5 days of the pet’s admission to C.C. Veterinary Hospital, said animal will be considered abandoned and may be disposed of as the veterinarian sees appropriate. It is also understood this action does not relieve me of any debt to C.C. Veterinary Hospital for expenses incurred. *

All procedures must be paid in full at the time of service by cash, check, VISA, MasterCard, Discover, or CareCredit, unless prior arrangements have been made and approved. *

I give C.C. Veterinary Hospital’s doctor’s and staff permission to provide services/procedures listed on page 1 of this document *

If fleas are observed on your pet while they are hospitalized, a Capstar pill will be administered to them at the owner’s expense of $8.00. *

I have seen estimates for procedures / treatments my pet may receive (see page 1). I understand this is only an estimate and may be subject to change. *

I am the owner / authorized agent of the animal described on this form and have the authority to execute this document. After carefully reading the above, I sign in agreement: *

Hospitalization Release

Hospitalization Release Form

Gentle care for peace of mind.

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