Client Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

Alternate Phone Number

Email *

Pet's Name *

Type of Pet *

Dog
Cat
Other

Sex *

Male (Intact)
Male (Neutered)
Female (Intact)
Female (Neutered)

Breed *

Color *

Age/Date of Birth

What is your primary concern today? Please describe in detail including when your pet started exhibiting these symptoms: *

Describe your pet's attitude and activity level *

How is your pet's appetite? *

Have you changed your pet's diet recently? *

Yes
No

What kind of food do you feed your pet at home?

Has your pet's environment changed (e.g. moved cities)?

If your pet has been vomiting or having diarrhea please describe:

If any other person is authorized to make decisions regarding the health and livelihood of your pet, please list their name and contact information:

Consent for Examination, Hospitalization, and Treatment: *

As the owner, or owner’s agent of the above animal, I hereby give my consent to the staff veterinarians at Lone Tree Animal Care Center to examine, and if appropriate, to hospitalize, prescribe medications for, and perform treatments as deemed necessary on my animal. In the event the veterinarian or staff is unable to reach me, I understand it is my responsibility to call the hospital daily to inquire as to the medical status of my pet. I acknowledge that the medical condition of my pet may drastically worsen in a short period of time. I realize that unforeseen events may occur during the period of hospitalization. Should some unexpected life saving emergency care be required, and should the situation or circumstances preclude my being contacted, LTACC’s staff has my permission to provide necessary treatment. I understand that I am responsible for all professional and hospital fees, including fees for medications and diagnostic procedures, and agree to pay, in full, for all services rendered. This responsibility continues in the event my pet fails to recover, dies, or is euthanized. I am encouraged to discuss all fees attendant to the care of my animal before services are rendered, and to request a written estimate of involved fees if one has not been provided to me. Any verbal or written estimate of charges or fees is only a best approximation, and the final charges may be less than or greater than this amount. I agree to pay a deposit of 60% of the estimated fees upon hospitalization, and to pay for the balance of all services rendered on a cash, credit card, or check basis upon discharge. I further agree that I, or an authorized agent, will pick up my pet and pay for all accrued charges within 5 days after receiving written or oral notification that my pet is ready to be released from Lone Tree Animal Care Center. Such notice will be given at the address maintained on the hospital’s patient/client record or the address listed below. I agree that if I fail to comply with this policy, LTACC will consider my animal abandoned and will proceed accordingly.
Any verbal or written estimate of charges or fees is only a best approximation, and the final charges may be less than or greater than this amount. I agree to pay a deposit of 60% of the estimated fees upon hospitalization, and to pay for the balance of all services rendered on a cash, credit card or check basis upon discharge. I further agree that I, or an authorized agent, will pick up my pet and pay for all accrued charges within 5 days after receiving written or oral notification that my pet is ready to be released from Lone Tree Animal Care Center. Such notice will be given at the address maintained on the hospital’s patient/client record or the address listed below. I agree that if I fail to comply with this policy, LTACC will consider my animal abandoned and will proceed accordingly.
I understand my pet will be checked for fleas upon arrival. If fleas are noted, LTACC will administer Capstar for immediate treatment, and will also apply a topical prevention that lasts 30 days. I understand the communicable nature of fleas/ticks, and will be held financially accountable for the treatments.

Client Signature *

Clear Signature

Signature Date *

LTACC Witness Signature: *

Clear Signature

Hospitalization / Admission Consent Form

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