Hoof & Paw Check-in Sheet/Informed Consent For Treatment and/or Day Admission CompanyThis field is for validation purposes and should be left unchanged.OWNER NAME First Last PET NAMEDate MM slash DD slash YYYY Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country I am over 18 years of age Yes No Pet Housed Indoors Outdoors Both Do you have pet insurance on this pet**? Yes No (Please note that payment is due at the time of service. We will provide you with a receipt to submit to the insurance company for reimbursement from the insurance provider.)Phone # you can be reached at todayPrimarySecondaryWOULD YOU LIKE TO RECEIVE TEXT MESSAGES ABOUT YOUR PET’S PROGRESS WHILE THEY ARE IN THECLINIC? Yes No If your pet has been seen at another clinic, is it ok to request records from the previous clinic? Yes No Clinic name and numberWould you like your pet tested for heartworm/lyme disease today? Yes No FIV/FeLeuk? Yes No DESCRIBE THE PROBLEM/SYMPTOMS THEY ARE HAVINGWhen did you first notice the problem?Has your pet had these symptoms in the past? Yes No Diarrhea? Yes No Vomiting? Yes No Normal appetite/water intake? Yes No Normal activity level? Yes No If necessary, can we sedate your pet? Yes No Rabies vaccinations on dogs MUST be current (State Law)SELECT ONE:★Please initial below to authorize the following diagnostic testing★ (If initialed, you will NOT be receiving a call and the doctor will perform tests at their discretion)*Bloodwork Approximate cost $150-$210 Yes No *Xrays Approximate cost $180-$260 Yes No Signature First Last Date MM slash DD slash YYYY INFORMED CONSENT FOR TREATMENTI understand that if I checked yes to “if necessary can we sedate your pet?” that Veterinary Medicine is an inexact science and some complications can arise such as (including, but not limited to) vomiting, constipation, and in rare cases death. I give permission to treat my pet, but will not hold Hoof & Paw Veterinary Clinic liable for any unforeseen circumstances that may arise.I understand that risks always exist with anesthesia and that I am encouraged to have pre-anesthetic bloodwork done and discuss any concerns and options with a Veterinarian before my pet is sedated.I am also aware that during the hours of 6 pm to 6:30 am there is NOT overnight staff to continuously monitor my pet at the Hoof & Paw Veterinary Clinic, and that upon my request and expense a referral to a 24 hour emergency clinic is an option that is available to me.I understand that Veterinary Medicine is an inexact science and there is no guarantee of successful treatment, but that it is our goal to provide the best attainable and humane care we can provide for your pet at our facility.Signature First Last Date MM slash DD slash YYYY
