Drop-Off Consent - Eastern Shore Animal Hospital

Owner Name*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Pet Name*

Species*

Breed*

Sex*

Male
Female

Color*

Weight*

Patient Procedure*

- I, as the owner or authorized agent of owner, grant my consent to the doctors and staff to receive, treat, and/or operate upon the above named pet. I understand that there is risk associated with medical and surgical treatments performed under sedation or general anesthesia. Specific results can never be guaranteed in dealing with the complexities of living animals. I understand that unforeseen complications can result; even though professional, approved, methods will be used by the doctors and staff of Eastern Shore Animal Hospital.
- I understand that if lives fleas or ticks are found on my pet that flea treatment is required and will be applied at personal cost.
- I understand that up-to-date vaccinations are required to leave my pet for treatment, all required vaccinations will be updated unless deemed inappropriate by the doctor examining my pet and will be done personal cost.
- I accept all financial responsibility for my pet and understand that payment for services rendered is due at the time of discharge.

Please read the following options carefully:*

In case of a medical emergency where extreme measures are required, the doctors and staff have my permission to perform what ever life saving procedures necessary in an attempt to save my pet.
In case of a medical emergency where extreme measures are required I request that the doctors and staff do not make attempts to resuscitate my pet, otherwise termed as DNR.

I have read and fully understand the terms and conditions set forth above.

Electronic Signature

Date*
MM slash DD slash YYYY

Date

Phone number at which owner can be reached today or tomorrow.*

Drop-Off Consent Form