Drop-Off Form

Due to the current COVID recommendations, we have elected to use this form to streamline the drop off process. Please complete this form and let us know when you are ready for a staff member to come out to get your pet. You can either call (919) 496-2638 or text (919) 729-6296. Please note, if we do not have your cell phone number we are not able to receive text messages from you. Thank you for your patience.

Client Name*

Patient Name*

Date

Being responsible for the above-described animal, I have the authority to grant you my consent to receive, prescribe for, treat and/or operate on my pet.

I authorize the personnel of Louisburg Veterinary Hospital to:

Text
Call

Best Contact Number*

Perform bloodwork as recommended for my pet.

Accept
Decline

Give medication in the hospital and prescribe for home use if needed for my pet.

Accept
Decline

Use fluid therapy for my pet if needed as determined by the doctor.

Accept
Decline

Update annual vaccinations or recommended diagnostic test; e.g. heartworm, medication rechecks, Feline Leukemia testing.

Accept
Decline

What do you feed your pet and when was he/she last fed?

Please list the reasons why we are seeing your pet today, and any concerns you may have.

List of current medications your pet is taking.

Are there any additional concerns you would like for us to address during this visit today?

I understand a written estimate for these services will be made available upon my request and that I will provide a 50% deposit for the estimated fees.

Accept

In an effort to maintain a flea-free hospital, if fleas are found on my pet upon admittance to Louisburg Veterinary Hospital, I agree to treatment with an appropriate oral or topical flea treatment to prevent spread of those parasite to other hospitalized patients. I understand I will be charged for this treatment.

Accept

I understand that Louisburg Veterinary Hospital is not responsible for personal belongings that are left with your pet. We do provide towels and blankets in the cages where all patients are kept.

Accept

While I accept that all procedures will be performed to the best of the abilities of the hospital's staff, I understand that no guarantee has been made regarding the results that may be achieved. I agree to assume financial responsibility and provide payment at the time that services are rendered.

Accept

General Information on CPR

Consent/Decline Directive for Cardiopulmonary Resuscitation and Release of Legal Liability

Should, based on the medical judgment of an Animal Diagnostic Veterinarian, my pet, require cardiopulmonary resuscitation (CPR), including cardiac compression, positive pressure respiration, emergency drugs, or other heroic interventions, I request or decline that the doctor(s) at Louisburg Veterinary Hospital pursue such medical care as indicated below.

REQUEST CPR

Having requested such emergency procedures, I agree to be held responsible for a minimum resuscitation fee of $150.00 to pay for the services performed while staff members pursue treatment and try to reach me for further directions. Regardless of my pet's survival, I agree to pay this fee in addition to the other fees already identified by the practice and agreed upon by me. I agree that if the Louisburg Veterinary Hospital staff is unable to reach me within 15 minutes after the initiation of CPR procedures, and after exercising reasonable medical judgment, a veterinarian determines that there appears to be virtually no hope for medical success, the future CPR procedures will cease. I have been informed by Louisburg Veterinary Hospital and understand that despite the best efforts of the veterinarian and staff at Louisburg Veterinary Hospital, CPR may not save my pet's life. I also understand that even the most successful CPR that restores my pet's life may not allow my pet to regain his/her normal mental and physical health, and thus may leave him/her as invalid.

I request CPR.

DECLINE CPR

DO NOT RESUSCITATE MY PET. I have read the above information and release. I agree to the above terms and request that NO CPR BE PERFORMED ON MY PET.

I decline CPR.

Electronic Signature*

Owner/Responsible Party

Date*

General Information on CPR

Louisburg Veterinary Hospital

Hospital Hours