Hospital Consent Form | The Village Vet Killara and Pymble

Hospital Consent Form

Please complete the following details.

Which Clinic are your visiting?(Required)

Pymble

Killara

Procedure Date:

DD slash MM slash YYYY

Procedure:

Patient:

Weight today

Age

Customer

Address

Phone

Alternative Contact No. if different for today:

Insurance

Pet Insurance?

Yes

If you wish to claim for today please let a nurse or receptionist know and we can submit it electronically for you.

Would you like us to make GAP claim for you?

Yes

Insurance Company Name

Insurance Policy Number

Questions

When did you pet last eat?

Please record any current medications your pet is on:

When was the last dose given?

Cost Estimate provided by vet?

Yes

Estimate of initial costs:

If "No" would you like us to provide you with one before proceding?

Yes

Permission to use photos we may take on social media?

Yes

I agree to payment of the fees when I collect my pet from the clinic

Your pet is being admitted into hospital today for a procedure or hospital treatment as outlined above. The vet or nurse may also call you with further updates and necessary treatments. If your petis staying in hospital overnight the vet will update you each day on estimated costs. I will be available throughout the day by phone, and if not I am happy to have my alternative contact make decisions on my behalf.

Please type your full name for acceptance

Signature

Date

DD slash MM slash YYYY

Internal only

Patient ID:

Customer ID:

Weight today

Description

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For more information regarding orders or our services, please contact us.

Call Killara: (02) 8350-5678 Call Pymble: (02) 9499-4010