Hospital Admission and Treatment Consent Form
Admission Details
- Date of admission
- Time of admission
- Expected length of stay
Client's Details
- First name
- Last name
- Address
- Best contact number while in hospital
- Alternate contact (name and number)
Patient's Details
- Name
- DOB (age)
- Microchip
- Weight (kg)
- Gender
- Species
- Breed
- Current medications
- Reason for admission / presenting problem
Treatment Plan & Estimate
- Planned treatment and diagnostics
- Estimated cost from ($)
- Estimated cost to ($)
- Deposit paid ($)
- I authorise treatment up to a total of ($)
- If costs are expected to exceed the estimate or the authorised amount
- Preferred update method
Resuscitation Election (CPR / DNR)
CPR (cardiopulmonary resuscitation) is emergency treatment attempted if an animal's heart or breathing stops. It may include chest compressions, a breathing tube and oxygen, emergency medications, defibrillation and, in some cases, emergency open-chest heart massage. Despite best efforts, most animals whose heart stops in hospital do not survive to go home, and survivors may need intensive aftercare. Recording your wishes now means staff can act immediately, and in line with them, in an emergency.
- If my animal's heart or breathing stops, I elect:
Full CPR includes open-chest heart massage where the veterinarian judges it necessary. DNR (do not resuscitate) means staff will not attempt resuscitation and will focus on comfort. This election applies to the current admission only, and you may change it at any time by telling staff.
- During an emergency
- Resuscitation notes
Consent
I consent to the admission and hospitalisation of the animal described above and to the treatment and diagnostic plan listed, subject to my contact election above. I understand that treatment and hospitalisation carry risks and that no outcome can be guaranteed. I acknowledge that the estimate above is an estimate and not a fixed quote, that costs can change as my animal's condition changes, and that I will be contacted in line with my election above if costs are expected to exceed the estimate or the authorised amount. I agree to remain reachable on the contact details above while my animal is in hospital, and to pay any deposit stated and all fees owing at the time of discharge. I have read the resuscitation explanation above and my election records my wishes if my animal's heart or breathing stops during this admission. I understand that resuscitation cannot be guaranteed to succeed and can incur significant cost, that a DNR election means staff will not attempt resuscitation and will focus on comfort, and that I may change my election at any time by informing staff. I confirm that I am over the age of 18 years and am the owner, or an authorised agent of the owner, of this animal.
- Owner / agent name
- Date signed
Owner / agent signature
- Admitting staff member
- Role
Staff signature