Fasted Procedure Check In Form

Name*

First Last

Pet's Name*

First

Name of person to reach while your pet is in our care*

First

Phone number of contact listed above*

How is your pet doing? Any Concerns?*

I understand that my pet is to arrive fasted, except for water, since midght on the morning of drop off. I will inform you at check-in if my pet had any food/treats the morning of drop off*

I Understand

Do we have permission to update any vaccines? (Rabies is required and will be updated if no current proof is provided unless pre-approval obtained from doctor)*

Yes
No

Explanation of vaccine requests (If Necessary)*

If a fecal sample is produced while your pet is in the hospital, would you like to have it sent to the lab to check parasites?*

Yes
No

Is your pet on any flea control?*

Yes
No

If yes, please tell us product name and date of last administration

If live fleas are seen on your pet, we will administer a fast acting flea medication for an additional cost*

I Understand

Has your pet been on any medications in the last 2 weeks?*

Yes
No

If yes, please tell us the names, dosages, and time of the last administration

Consent*

I Understand

I, THE UNDERSIGNED OWNER OF THE ABOVE PATIENT, AUTHORIZE MCMONIGLE VETERINARY HOSPITAL'S DOCTORS AND STAFF TO TREAT MY PET AND TO PERFORM ANY PROCEDURES THAT ARE MEDICALLY INDICATED. I UNDERSTAND THAT NO GUARANTEE OF SUCCESSFUL TREATMENT IS MADE. I, THE OWNER, ASSUME FULL FINANCIAL RESPONSIBILITY FOR ALL CHARGES INCLUDING COMPLICATIONS DURING OR AFTER SURGERY. I FURTHER UNDERSTAND THAT ALL ANESTHETIC AND SURGICAL PROCEDURES INVOLVE SOME DEGREE OF RISK FOR MY PET. I UNDERSTAND THAT IT COULD BE MEDICALLY RECOMMENDED THAT MY PET BE TRANSFERRED TO STAY OVERNIGHT AT AN EMERGENCY HOSPITAL AFTER CERTAIN PROCEDURES OR IF MY PET HAS ANY COMPLICATIONS. I UNDERSTAND THAT IF MY PET STAYS OVERNIGHT AT MCMONIGLE VETERINARY HOSPITAL THEY WILL NOT BE UNDER OBSERVATION AS WE DO NOT HAVE STAFF IN THE HOSPITAL DURING THIS TIME PERIOD.

Consent*

I Understand

I HAVE RECEIVED AN ESTIMATE FOR THE MEDICAL CARE PLAN THAT WILL BE CARRIED OUT AT THE DISCRETION OF THE DOCTOR. THE ESTIMATE RANGE (ATTACHED IN MY EMAIL) IS SUBJECT TO CHANGE AS THE DOCTOR PROCEEDS AND ITEMS MIGHT NOT LINE UP EXACTLY ON MY FINAL INVOICE. I ACKNOWLEDGE THAT CHANGES IN MY PET'S CONDITION OR DISCOVERY OF OTHER FINDINGS DURING TREATMENT MAY NECESSITATE A CHANGE IN OR AN EXTENSION OF THE ORIGINAL ESTIMATE AND IF THIS OCCURS, A STAFF MEMBER WILL ATTEMPT TO CONTACT ME TO UPDATE THIS FIGURE. IN THE EVENT I CANNOT BE REACHED, MCMONIGLE VETERINARY HOSPITAL HAS PERMISSION TO PROCEED WITH MEDICAL CARE FOR A) A LIFE-THREATENING CONDITION OR B) ADDITIONAL SERVICES THAT WILL PRESERVE OR ENHANCE MY PET'S HEALTH OR C) MINIMIZE THE NEED FOR, AND RISK OF, ADDITIONAL SERVICES AT A LATER DATE. I AGREE TO PAY FOR SERVICES RENDERED AT THE TIME OF DISCHARGE WITH CASH, DEBIT, VISA, MASTERCARD, AMERICAN EXPRESS, DISCOVER OR CARE CREDIT.

Consent*

I Understand

IF I DO NOT BRING MY PET TO THIS APPOINTMENT, I UNDERSTAND THAT I WILL BE RESPONSIBLE FOR PAYING A $425.00 FAILED APPOINTMENT FEE FROM THE CARDIOLOGIST AND RESCHEDULING WILL COME WITH RESTRICTIONS.

Consent*

I Understand

I AM RESPONSIBLE FOR PICKING UP MY PET BEFORE 5:00PM ON THE DAY OF SURGERY. IF I AM LATE AND PICK UP MY PET AFTER HOURS, I UNDERSTAND I WILL BE CHARGED A LATE PICK UP FEE OF $50 PER 30 MINUTES.

Consent for CPR or DNR

You are being presented with this form because your pet is being hospitalized. In the unlikely event that an emergency happens, such as if your pet suffers respiratory arrest (stops breathing) or cardiac arrest (the heart stops), we have an advanced directive in place to ensure your wishes are followed. Our staff is trained to immediately begin CPR and life-sustaining measures unless otherwise directed. This does incur an additional cost not quoted on the estimate or treatment plan. If you elect to decline this protocol, you understand that you are giving the doctors and staff at McMonigle Veterinary Hospital a “Do Not Resuscitate” directive. CPR means “Cardio Pulmonary Resuscitation” and is the treatment (resuscitation) of a pet who has stopped breathing or whose heart has stopped beating. DNR means “Do Not Resuscitate.” This means that if a pet stops breathing, or his/her heart stops, no effort will be made to attempt to revive the pet, and we may discuss administering medications to facilitate a calm and complete passing. Animals that have been successfully resuscitated are extremely critical and unstable. The likelihood of re-arrest is high and usually occurs within 4 hours of the initial arrest. Management of a pet after successful initial resuscitation requires vigilant monitoring for at least 24 to 48 hours. You will be required to transfer your pet to an emergency facility such as Blue Pearl Emergency Hospital or Summit Veterinary Referral Center for post resuscitation continued monitoring. This will incur additional expenses through the emergency facility.

CHOOSE ONE OPTION*

CPR - I wish for the staff of McMonigle Veterinary Hospital to perform CPR (resuscitation) on my pet if my pet suffers respiratory or cardiac arrest, I understand that my pet may respond initially and then suffer another arrest later. I understand that my pet might die despite CPR. The estimate for initial CPR is $300 to $500+. Regardless of my pet’s survival, I agree to pay this fee and any additional expenses incurred in addition to the other fees already identified and agreed upon by me.
DNR - I DO NOT want CPR performed on my pet. I understand that if my pet stops breathing and/or their heart stops beating, that my pet will die unless CPR is performed. I elect to place DNR (Do Not Resuscitate) orders on my pet’s record OR I elect that the veterinary staff stop the initial attempts at CPR that may have been started while I was being informed of the condition of my pet and options.

Consent*

I have read and understood the information above or had it explained to my satisfaction.

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Consent for CPR or DNR

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