Hospitalization Consent Form

Save time during your appointment! Complete your hospitalization consent form online from any device at any time before your visit.

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Hospitalization Consent Form

In the event your pet is admitted into our hospital, we will require your review, authorization, and signature of this form.

Owner’s Name *

First

Last

Email *

Phone number where you can be reached today: *

Secondary phone number where you can be reached today:

Pet's Name *

I certify that I own/have assumed financial responsibility for my pet written above. I do hereby consent and authorize Dr. Marsch and his staff to hospitalize my pet. I also hereby authorize the administration of vaccinations, medications, tests, surgical procedures, anesthetics, or treatments that Dr. Marsch deems necessary for the health, safety, or well‐being of my pet while he/she is under their care and supervision. I have been informed that an attendant will not be at the hospital 24 hours a day. Someone will be checking on all hospitalized pets at frequent intervals, but they do not spend the night. *

I have read and understand

If my pet written above should injure himself/herself in an escape attempt, refuse food, soil himself, become ill, or die while in the hospital, I will hold East Side Animal Hospital free of any responsibility and liability in the absence of gross negligence. *

I have read and understand

I further realize that I am responsible for payment in full of all procedures & treatments provided during the time of hospitalization at the time my pet is discharged. If I neglect to pick up my pet within five days of written notice that he/she is ready for release and mailed to my address on file, I understand my pet is then considered abandoned. If my pet is deemed abandoned, I authorize East Side Animal Hospital to dispose of it as seen fit. Abandonment does not release me of my obligation for the bill. *

I have read and understand

A deposit of 50% of the estimate for the first 24 hours of hospitalization is required on admission. If an estimate is not available, the deposit for new clients is $100.00 and for established clients $75.00. *

I have read and understand

Signature *

Clear Signature

Date *

Hospitalization Consent Form

Hospitalization Consent Form

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