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

Name

First Name Last Name

Email Primary Contact Phone for stay Secondary Contact Phone for stay Pet's name What is your concern(s) with your pet? How long has your pet had these symptoms? What specifically is your pet doing? When do you notice these symptoms or are there any activities that exacerbate these symptoms? 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 heartworm prevention is your pet on? When was their last dose of heartworm given? What flea & tick prevention is your pet on? When was their last dose of flea and tick prevention given? What diet do you feed your pet? How much and how often do you feed your pet? What medications (medication name, strength, dose and frequency) is your pet on? List any supplements, over the counter medications or CBD that you give your pet including the amount and frequency you give it.

Would you like a nail trim done on your pet today? ADDITIONAL FEES MAY APPLY.YesNo

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.

EMERGENCY CARE

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. CPRDNR

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. Type your full name

Treatment Consent Form