Drop-Off Hospitalization Form Drop Off Form for Hospitalization or Treatment Client Name * Client Name First First Last Last Email * Phone * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Patient Name * Species * Breed * Sex * Color * What medication(s) is your pet currently taking? * What medication(s) is your pet currently taking? * Phone number(s) at which owner can be reached today or tomorrow * If pain medication or antibiotics are necessary following the procedure which would you like Tablets Liquid I understand that some risks always exist with procedures, anesthesia and/ or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. I give the staff at Lincolnway Veterinary Clinic permission to proceed with procedure/surgery. * I understand In the event that something unforeseen should occur while your pet is under the care of Lincolnway Veterinary Clinic and life saving measures would need to be performed I: * Would prefer that my pet pass without any sort of resuscitative measures taken. Would like any life-saving procedures should the need arise be taken to the best of the doctors' ability until I can be contacted. Further I understand that I am financially responsible for all costs incurred during this process. Lincolnway Veterinary Clinic will be returning any leashes or carriers to the owner at the time of dropping a patient off for a hospital stay. I understand that it is my responsibility to bring the appropriate items back to the clinic upon pickup of my pet. Furthermore, I understand that if I do not have the appropriate items to pick my pet up it will be my responsibility to obtain them or to purchase a leash or cardboard carrier directly from Lincolnway Veterinary Clinic. If I chose to carry my pet out of the clinic without a leash or carrier I understand that it is my responsibility to get my pet safely to my vehicle and I release Lincolnway Veterinary Clinic and its staff from all responsibility for my decision. * I understand I have read and fully understand the terms and conditions set forth above. * I understand Signature * signature keyboard Clear Date * Captcha Submit If you are human, leave this field blank.
