Roncesvalles Animal Hospital

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Hospitalization and In Clinic Procedure Consent Form

Home > Hospitalization and In Clinic Procedure Consent Form

Please complete these questions prior to your visit with us for your pets in clinic appointment.

Name(Required)
Are you the individual responsible for decisions and accounts for the pet listed below?(Required)
This person should be the owner on account, responsible for decisions and payments and of legal age.
Email(Required)
Please keep your phone on and be available to answer it while we have your pet in the clinic.
MM slash DD slash YYYY
I understand that there will be periods of time when my pet can be left unattended at the hospital. There is no staff on the premises during the late evenings, overnight, after hours or on the weekends and holidays. Although we are open 6 days a week, we are not a 24-hour facility, nor a veterinary emergency hospital. Roncesvalles Animal Hospital staff comes into the clinic after hours to be able to monitor in clinic patients. It is always recommended to proceed to an emergency clinic for 24 hours care rather than be left in the clinic after hours, with limited monitoring by staff(Required)
I authorize the performance of the identified procedures listed above and the use of associated anesthetics and other medications. I also understand that unforeseen conditions may be revealed during the identified procedures which, if in the opinion of the attending veterinarian require more extensive or different procedures or treatments, I authorize the vet use their judgment as needed. I understand that reasonable efforts will be made to contact me to explain these procedures and treatments and obtain my instructions regarding them. However, if the efforts are unsuccessful, I authorize the performance of any procedures and treatments which are necessary in the professional opinion of the attending veterinarian. Additional charges may apply. We will make every effort to keep within the estimate but sometimes procedures take longer than expected or differ from the estimate and the price may vary.(Required)
I understand I agree to pay a deposit of at least 50% of the estimate prior to the procedure(Required)
I agree to pay the total balance as per the estimate given, for the above procedures and related clinic fees. I will pay the balance at the time the pet is discharged and hereby acknowledge my indebtedness for this amount. In the event that the pet referred to above is not claimed by the person giving consent within five (5) days of completion of treatment and convalescence or of any ancillary services provided by the Roncesvalles Animal Hospital, the pet shall be deemed to have been abandoned, and the Clinic shall be entitled to transfer the pet to an animal shelter or to a third (3rd) party owner willing to adopt the cat. The Clinic waives its lien rights under the Repair and Storage Liens Act. Abandonment does not release me of my obligation for payment of services rendered.(Required)
At times during your pet’s visit, we may take pictures. Your consent here will act as authorization to use these pictures on Roncesvalles Animal Hospital Facebook, Instagram and social media pages.(Required)
Cancellation Policy(Required)
I have read and understand this complete form, any questions and concerns will be noted in the below field(Required)

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