Loading...

Admission Form 


December 7, 2022

I Agree
I understand that the cost involved in the requested procedure(s) are to be paid in full at the time of my pet's release.

I Agree
I am the owner or agent of the above named pet and herby authorize the performance of the requested procedure(s).  I understand that unforeseen conditions may necessitate an extension of the procedure/treatment or a change in the plan and therefore authorize such action as are necessary in the professional judgement of the veterinarian. I authorize the use of appropriate anesthetics and medications. I have been advised of the nature of the procedure and I understand that while every effort will be made to provide the best care for my pet, results cannot be guaranteed. 

I Agree
I have read the above information. I understand and agree to the conditions and policies of Lebanon Small Animal Clinic. Inc.


First Client Name

First Name*

Last Name*

Phone*
First Client Date of Birth*
I certify that I am 18 years of age or older
First Client Pet's Name

Name of Pet *

Procedure(s) *
Would you prefer us to call or text you for updates/questions?*
First Client Signature*
Second Client Name

First Name*

Last Name*
Second Client Date of Birth*
Second Client Pet's Name

Name of Pet *

Procedure(s) *
Would you prefer us to call or text you for updates/questions?*
Third Client Name

First Name*

Last Name*
Third Client Date of Birth*
Third Client Pet's Name

Name of Pet *

Procedure(s) *
Would you prefer us to call or text you for updates/questions?*
Fourth Client Name

First Name*

Last Name*
Fourth Client Date of Birth*
Fourth Client Pet's Name

Name of Pet *

Procedure(s) *
Would you prefer us to call or text you for updates/questions?*
Fifth Client Name

First Name*

Last Name*
Fifth Client Date of Birth*
Fifth Client Pet's Name

Name of Pet *

Procedure(s) *
Would you prefer us to call or text you for updates/questions?*
Sixth Client Name

First Name*

Last Name*
Sixth Client Date of Birth*
Sixth Client Pet's Name

Name of Pet *

Procedure(s) *
Would you prefer us to call or text you for updates/questions?*
Seventh Client Name

First Name*

Last Name*
Seventh Client Date of Birth*
Seventh Client Pet's Name

Name of Pet *

Procedure(s) *
Would you prefer us to call or text you for updates/questions?*
Eighth Client Name

First Name*

Last Name*
Eighth Client Date of Birth*
Eighth Client Pet's Name

Name of Pet *

Procedure(s) *
Would you prefer us to call or text you for updates/questions?*
Ninth Client Name

First Name*

Last Name*
Ninth Client Date of Birth*
Ninth Client Pet's Name

Name of Pet *

Procedure(s) *
Would you prefer us to call or text you for updates/questions?*
Tenth Client Name

First Name*

Last Name*
Tenth Client Date of Birth*
Tenth Client Pet's Name

Name of Pet *

Procedure(s) *
Would you prefer us to call or text you for updates/questions?*
Other Agent/Contact

Please list any other agent and their phone number (16 years old or older) that is able to make medical and financial decisions for this treatment/procedure.
Parent or Guardian's Email Address

Email*

Confirm Email*
Fasting/Medications
Has your pet eaten anything in past 12 hours?*
No
Yes
Has your pet had any medication in the past 24 hours?*
No
Yes

Please list medications and time given.
Medical History
Has your pet had any vaccinations within the last 12 months:*
No
Yes

We require verification if not performed here at LSAC. Please list Veterinarian and Dates administered.
Has your pets been treated for fleas within the past 30 days?*
No
Yes

Product and Date of Administration
Has your dog been tested for Heartworms in the past Year?*
Yes
No
Not applicable to other species (cats, pocket pets, exotics, etc)
Treatment
Do we have authorization to treat your pet while they are here is we see a problem that was not previously discussed? (i.e. ear infection, skin infection) Additional charges may apply. If we are unable to reach you, please know that no further treatment will be performed. *
Additional Requested Procedures
Nail Trim
Express Anal Glands
Ear Cleaning
Microchip Implant/Registration
Heartworm Test
FeLV/FIV (Feline Leukemia Test)

Please list any additional procedures you would like.
CODE STATUS
Every effort will be made to provide the best care for your pet, but in the event that your pet's heart and breathing should stop, do you elect:*
If your pet requires pain medication to be sent home, would you prefer:
Click to customize checkboxes
Tablet/Capsule
Liquid
The Dr. has already prescribed the medication and I have it at home.
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Pet's Name

Name of Pet *

Procedure(s) *
Would you prefer us to call or text you for updates/questions?*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!