FM 1488 Animal Medical Center

ALL PETS MUST BE IN A CRATE OR ON A SECURE LEASH PRIOR TO YOUR ARRIVAL.

Name

First NameLast Name

Email

Primary Contact Phone for stay

Enter phone numberFormat: (000) 000-0000.

Secondary Contact Phone for stay

Enter phone numberFormat: (000) 000-0000.

Client's initials

Pet's name

Reason for visit

Are there any new problems or concerns you would like addressed while your pet is here?

has your pet had any new coughing?

has your pet had any new sneezing

has your pet had any vomiting

has your pet had any diarrhea or blood in their stool

What medications (medication name, strength, dose, and frequency include any supplements, over the counter medications, and/or CBD products used) is your pet on?

list any supplements, over-the-counter medications, or CBD that you give your pet including the amount and frequency yougive it

does your pet have any history of seizures

do you want your pet to have a microchip implanted while here for surgery?

do you want your pet to have at home sedation post-operatively to help keep them calm and quiet for an additional charge?

WOULD YOU LIKE A NAIL TRIM DONE ON YOUR PET TODAY? ADDITIONAL FEES MAY APPLY.

If you have any pictures or videos of the concerns you have for your pet today, please email those to recordsfm1488amc@gmail.com

Acknowledgment of Consent:

I understand that I am leaving my pet in the care of FM 1488 Animal Medical Center.

I understand that contact concerning my pet's veterinary care will be done via the telephone with the first available attending Veterinarian upon completion of the physical examination for patients dropping off for veterinary services. Pets having a planned surgical procedure will be contacted by a member of the veterinarian surgical team.

I understand that the Veterinarian may make recommendations that go beyond the original estimated costs presented at check in and these additional costs will be provided to me verbally. I understand that FM 1488 Animal Medical Center will accept verbal authorizations for the treatment of my pet and that an emailed copy of all additional estimates will be provided to me only at my request.

I understand that no guarantees have been made to me as to the results of the veterinary treatment for my pet.

Extended care:

I understand that FM 1488 AMC is NOT a 24 hour facility. There are no clinical staff available to monitor or treat patients overnight and/or on weekends.

I understand that in the event the attending veterinarian is not able to reach me, that it is my responsibility to contact FM 1488 Animal Medical Center at least once every 24 hours to check on the status, medical plan, and fees incurred for my pets care.

Sedation or Anesthetic care:

I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with my pet's attending veterinarian before any procedure is initiated.

I understand that the Veterinarians of FM 1488 Animal Medical Center will/have advise(d) me as to the nature of the surgical procedure being performed on my pet and the associated risks involved.

ADDENDUM FOR DENTAL PROCEDURES: I acknowledge and authorize the attending veterinarian to perform any and all dental extractions as deemed medically necessary for the health of my pet.

ADDENDUM FOR SPAY PROCEDURES: I understand that if it is determined that my pet is pregnant or in heat at the time of the spay, there will be an additional charge for this procedure above the estimate already provided.

EMERGENCY CARE

In the event that my pet should have an unexpected event requiring emergency, life saving care, I authorize the attending veterinarian(s) to provide such treatment (CPR initiation) at additional costs above any previous estimates provided.

Please fill in Dollar Amount:

This is the dollar amount we are authorized to charge.

I certify that I am over eighteen years of age and am aware that in the event an unforeseen emergency that causes my pet's heart to stop and/or my pet stops breathing while in the care of FM 1488 Animal Medical Center, *I DO NOT WANT ANY PERSON TO ATTEMPT RESUSCITATING MY PET. * I do hereby give the veterinarians of FM 1488 Animal Medical Center permission to euthanize my pet in the event of an unforeseen cardiac or respiratory arrest episode occurs while my pet is in the care of FM 1488 Animal Medical Center.

This order will stay in effect on the date signed and remain in effect until it is revoked by me in writing.

Initial Here

All patients treated by this hospital are required to have an Emergency Care Directive including Cardiopulmonary Resuscitation (CPR) or Do Not Resuscitate (DNR) code on file for each drop off event with our facility.

It is not likely we will need this information, but as is common practice in human medicine, we would like you to think about how you would like us to proceed in the unlikely event of an emergency. CPR is the resuscitation of an animal that has stopped breathing or whose heart has stopped beating. Animals that survive cardiopulmonary arrest and have been successfully resuscitated (CPR) are extremely critical and unstable. The likelihood of re-arrest is HIGH and usually occurs within 4 hours of the initial arrest.
The chances of long term “normal” survival can be extremely low and may be as little as 1%.

Management of the post-arrest patient requires vigilant monitoring and the technical expertise of dedicated critical care personnel at a specialty hospital. The care is costly, and the outcome is uncertain.

In the event that my pet should have an unexpected event requiring emergency, life saving care, I authorize the attending veterinarian(s) to provide such treatment (CPR initiation) at additional costs above any previous estimates provided.

CPR- I DO want the staff to perform closed-chest CPR (resuscitation) on my pet if my pet suffers from cardiac or respiratory arrest. I understand that my pet may not respond to CPR and may die despite CPR. I also understand that if my pet responds to CPR it is likely that he/she will arrest again. I acknowledge that the initial cost of CPR is $200-$500 and that for necessary aftercare, I will transfer my pet to a specialty critical care monitoring hospital that could cost thousands more. I understand that the cost could substantially exceed this estimate. I understand payment will be required either during my absence or immediately upon my return. I accept this financial responsibility and agree to pay for all services rendered. I understand that the staff will contact me immediately upon the initiation of CPR and if I am not available will proceed at the discretion and under the direction of the attending veterinarian until I can be reached.

Initial Here

DNR- I DO NOT want CPR performed on my pet. In the event of an emergency I wish for FM 1488 Animal Medical Center to move forward with Humane Euthanasia (if possible). I understand that if my pet suffers from cardiac or respiratory arrest, my pet will die. I have elected to have a DNR (Do Not Resuscitate) order placed on my pet’s record. I understand that even in this unlikely event, payment will be required for services rendered prior to my pet’s arrest. I accept this financial responsibility and agree to pay for all services rendered.

Initial Here

I hereby consent and authorize the Veterinarians at FM 1488 Animal Medical Center to perform the recommended veterinary services and/or procedures on my pet. I agree to assume all financial responsibility for the cost incurred for this veterinary care.