Patient Drop-Off Form

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Brandon Lakes Animal Hospital Patient Drop-Off

Name *

First

Last

Phone *

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Email *

Pet's name

Please provide a brief history of the reason for visit:

Please check the boxes below to ensure you understand what is being asked of you

If your pet is presented to the hospital with fleas, we will give is a safe flea medication to eliminate the fleas. The cost of this service is $10.00
Some animals can become frightened or aggressive while in an unknown environment, making it difficult to examine. If this case I give my consent for the Doctor(s) to use necessary sedation for my animal. I understand that if this is the case there will be a fee. I realize that there is a risk (although small) involved with any type of sedation and those risks have been explained to my satisfaction.
We try our best to provide you with an accurate estimate of charges, however there are times that we must alter the initial estimate that you were given. In that event we will call you to discuss charges with you.
A pre-payment equal to the estimated amount is required. Should the payment exceed the final bill, the balance will be refunded or credited to your account.

Resuscitation Order

Please read the following carefully and initial next to procedures you wish to be performed in the case of an emergency.

In the event of cardiac or respiratory arrest I authorize the responsible veterinarian to resuscitate my pet by performing one or more of the following procedures:

Yes to resucitation: External Cardiac Massage (CCPR) Cost range $100-$400.
Yes to resucitation: Internal Cardiac Massage Cost Range $1000-$2000
No to resucitation: I consent in the event of cardiac or respiratory arrest that NO attempts to resuscitate my pet be performed.

Post-resuscitation procedure care most likely will include overnight monitoring at a 24-hour emergency facility at additional cost to the pet owner.

Signature *

I understand that I assume financial responsibility for all services rendered, and that payment is expected on the day of surgery. Any medications and supplies purchased will be at an additional charge.

Date / Time *

Patient Drop-Off Form

Brandon Lakes Animal Hospital Patient Drop-Off

Resuscitation Order

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