Owner's Name *

First

Last

Patient's Name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Sex *

Male
Neutered Male
Female
Spayed Female

Age *

Species *

Phone *

Color

Hospital Check-In

Layout

Treatment Plan

What is your pets current food? *

Canned
Dry

What is the name of your pets food?

Does your pet have drug/vaccine reaction? *

Yes
No

If yes, please list

Has your pet had any history of seizures and/or any previous anesthetic problems? *

Yes
No

Is your pet currently on any medications?

Is your pet in heat or pregnant? *

Yes
No

Owner authorization and release

If your pet comes in with fleas, we will administer a flea and tick treatment at the cost of $10

◉ I am consenting to admit my patient into the hospitalized care of Northside Veterinary Hospital and the doctors in charge of my pet’s care.

◉ I have been provided with a general or itemized estimate regarding the desired treatment plan for my pet. I understand that this hospital is not staffed outside of operating hours, and therefore my pet may be unattended overnight.

◉ Complications are a part of the risk in any medical/surgical procedure. I understand that unforeseen complications may occur during the hospital stay or after discharge. These complications may increase my bill. I can receive billing updates if requested.

◉ I am aware that medicine, surgery, and anesthesia are not exact sciences, and that variable outcomes may occur.

◉ No guarantees have been made or implied concerning the results of the procedures. Regardless of the outcome, I understand that all charges are incurred based off the costs associated with the necessary treatments plan, and these charges will be my responsibility to pay in full.

◉ We do encourage owner visits while your pet is in the hospital. If you would like to visit , please try to keep visits between the hours of 10-12 and 1:30-3:30. Let your hospital technician know when you are planning to visit so that we can ensure your pet is not undergoing treatment at that time.

How would you prefer updates via phone call or text message? *

CALL
TEXT

Signature *

Clear Signature

Date *

Who will be picking animal up?

Phone Number *

Hospital Check-In Form

Hospital Check-In Form

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