Hospital Authorization Form

Client's Name*

First Name Last Name

Phone*

Email

Date of your pet's procedure*

MM

DD

YYYY

Who can we contact during your pet's stay with us?*

First Name Last Name

Phone*

Secondary Contact

In case we can not reach the contact person, please give us the name and phone number for an authorized person who can make decisions for your pet.

First Name Last Name

Phone

Pet's Name*

Procedure(s) or services being performed*

Does your pet have any known allergies or any adverse reactions to medications or anesthesia?*

Yes
No

Please explain:*

Does your pet have any known medical conditions?*

Yes
No

Please explain:*

Has any aspirin or other over-the-counter medications been given to your pet in the past two weeks?*

Yes
No

What medication was given?*

Click the plus symbol to add additional medications.

Medication name and strength	Quantity given	Last date & time given prior to procedure

Is your pet currently on any medications?*

Including heartworm, flea and tick preventatives.

Yes
No

Medications*

Click the plus symbol to add additional medications.

Medication name and strength	Quantity given	Last date & time given prior to procedure

Has your pet been tested for heartworm/FeLV/FIV in the past 12 months?*

Yes
No

Do you want your pet to be microchipped while he/she is with us?*

Yes
No
Already microchipped

Does your pet need any additional procedures while he/she is with us?*

Yes
No

What else would you like done?*

If your pet is coming in for grooming, what type of haircut do you want?

Is your pet coming in for surgery for a lump/mass removal?*

Yes
No

Biopsy: If applicable, do you authorize NPAH to submit your pet's mass for biopsy? (please give answer along with location for each mass)*

Click on the plus sign for each additional mass if there is more than one.

Location of Mass (please be as descriptive as possible)	Biopsy: Yes or No?

Laser Therapy: For orthopedic surgery patients

We recommend postoperative therapeutic laser treatments for pets having orthopedic procedures. The therapeutic laser is an application of light energy at the area of surgery to stimulate healing and reduce inflammation and discomfort.

We recommend a postoperative laser package that includes 6 postoperative treatments that will be performed every other day.

Would you like laser treatment for your pet?

Yes
No

Post Operative Collars: For surgery patients

If applicable, your pet will go home wearing a post surgical collar (e-collar)to deter him/her from licking or biting at the suture or incision area. The cost of this collar has been factored into your pet’s treatment plan. We have an upgrade option of a Comfy Cone, which are softer and easier to adjust. (Price difference is an additional $10-$30 depending on size of collar)

Depending on the location of the incision, we also offer After Surgery Wear as an alternative to an e-collar. (Price difference is an additional $10-$20 depending on the size)

Your choice (collar or surgery wear)*

Regular e-Collar (included in estimate)
Comfy Cone Collar (additional $20 to $55 depending on size)
Surgery Wear (additional $20 to $35 depending on size)
Already own an e-collar (please bring when you drop off your pet)

Is your pet coming in for a dental procedure?

Yes
No

Dental Procedures

Estimates for oral surgery and periodontal treatments are given based on the preliminary oral exam on the awake patient. However we cannot give an accurate estimate for these procedures until we have cleaned the teeth, taken radiographs, and done an in depth exam of the oral cavity under anesthesia.

If oral surgery or periodontal treatments are required, we will call you while your pet is under anesthesia to discuss the treatment options, and give you an updated estimate. We will not perform any procedures without consent, therefore if we cannot reach you or another authorized person by phone we will have to wake your pet up from anesthesia, and the procedures will be performed at another time.

Consent*

I have read and acknowledge the above procedure

Resuscitation Order*

Should some unexpected life-saving emergency or immediate care be required and the attending veterinarian is unable to reach me, this practice’s staff has my permission to provide such treatment and I agree to pay for all related fees

Yes, do CPR
No, do not resuscitate (DNR)

Authorization: Please read, consent and sign below.

I, the undersigned owner or authorized agent of the owner, certify that I am over eighteen years of age and hereby consent and authorize North Penn Animal Hospital to perform the above described procedures and services. Furthermore, I agree that after consultation with me, the hospital’s doctors may prescribe medications for, treat, hospitalize, sedate, anesthetize and or perform surgery of this animal. 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 the attending veterinarian before the procedure is initiated.

If my pet is hospitalized beyond this day at this facility, I understand that veterinary care during nighttime hours and/or weekends is provided at the discretion of the attending veterinarian. Continuous presence of hospital personnel is not provided overnight or throughout the weekend. If you are uncomfortable with this, please speak to your attending veterinarian.

I further agree that either I, or an authorized agent of mine, will pick up this pet and pay for all accrued charges when my pet is discharged from North Penn Animal Hospital. I assume full financial responsibility for all expenses involved including monthly billing and services charges that will be added to my invoice if special billing arrangements have been made. Our payment options are Cash, Personal Check, Debit, Visa, MasterCard, American Express or CareCredit.

Consent

I agree

Digital signature

First Last

Date*

MM

DD

YYYY

Important:

Once you click Submit, you will see a message that says your form was successfully submitted. If you do not, please scroll the form for missing information.

Monday	8:00am – 8:00pm
Tuesday	8:00am – 8:00pm
Wednesday	8:00am – 8:00pm
Thursday	8:00am – 8:00pm
Friday	8:00am – 8:00pm
Saturday	9:00am – 2:00pm
Sunday	Closed

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Hospital Authorization Form