Diabetic Lodging & Medical Lodging Consent Form Diabetic Lodging & Medical Lodging Consent Form Name * Name First First Last Last Date * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Emergency Contact Number * Email * Pet’s Name * Breed * Color * Age * Sex * Weight * Arrival Date * Departure Date * Our hospital policy is that we treat your pet as if it were our own. Has this pet ever bitten, scratched, or shown aggression toward anyone in any situation? * Yes No If yes, please explain What kind of diet is your pet on? * Does your pet prefer * Dry Canned Own Food What time is your pet fed and how much? * DIABETICS What type of insulin is your pet on? How much insulin does your pet receive What time do you give your pet’s insulin? Did your pet receive their food and insulin this AM? Yes No If yes, What time? PLEASE LIST ANY ADDITIONAL MEDICATIONS THAT WE NEED TO GIVE WHILE YOUR PET IS HERE Medication Dosage & Time plus1 Add another medication minus1 Remove a medication Please list any medical conditions we need to be aware of I would like the following additional procedures performed I understand that if I am not a current client of Limerick Veterinary Hospital, my pet will have an exam when entering medical lodging at an additional cost to me. This is to assess your pet’s health and treatment at our facility. If my pet’s medical status should change in any way while lodging, I authorize the doctor to add any treatments or medications necessary at an additional cost to me. I understand that if complications arise, the doctor may make the decision to enter my pet into the hospital as a patient and this will accrue additional costs to me. * I understand All charges shall be paid upon release from the hospital. If the pet is not called for within seven (7) days after the time specified for return, and if the doctor is not notified in writing of an alternate date within the seven day period, the animal will be considered abandoned, the hospital may handle this abandonment in a manner that is in the best interest of the pet and hospital. It is understood that this does not relieve me from paying for all costs of your services and use of your hospital including the cost of boarding. Should it be necessary to assign this account to a licensed collection agency or attorney, the applicant agrees to pay all subsequent collection and/or legal fees. I, being responsible for the above-described animal, have the authority to grant you my consent to prescribe for, treat, and operate upon my pet if the doctor deems this necessary. After carefully reading the above, I have signed in agreement. Owner or Responsible Party * signature keyboard Clear Today's Date * Resuscitation Consent Orders As a standard precaution- we are asking everyone who admits an animal into the hospital to fill out the following form. In the event of an emergency and your pet’s health starts to deteriorate, we need to know how to proceed if we are unable to contact you. Client’s Name * Client’s Name First First Last Last Pet’s Name * Effective Date * I, the undersigned owner or owner’s authorized agent of the pet identified above, certify that I am over eighteen years of age, and I understand that my pet may deteriorate during the course of treatment while at this facility. While I understand every attempt will be made to contact me if my pet’s condition worsens, I authorize the following: I hereby request that in the event my pet’s heart and or breathing should stop, every reasonable effort shall be attempted to save its life. I understand that the prognosis for my pet is uncertain; I authorize you to attempt to resuscitate my pet by means of an endo-tracheal tube, positive pressure respiration, emergency drugs, CPR and surgery if required; I understand there are no guarantees for a successful outcome. I understand that these services will require considerable time, effort and cost. I agree to pay these costs regardless of his/her survival. I request I hereby request that in the event my pet’s heart and or breathing should stop, no person shall attempt to resuscitate my pet. I request Phone * Owner’s Signature * signature keyboard Clear Date * Captcha Submit If you are human, leave this field blank.