Skip to content
For Dogs · WOOPF™, opens in a new tabCare about your pet? Download ASK A VET!For Cats · PURRZ™, opens in a new tab
ASK A VET

Hospital Admission and Treatment Consent Form

A free fillable hospital admission consent for veterinary use, with the treatment estimate, deposit, authorised amount, contact elections and CPR/DNR resuscitation election all recorded in one signed document. Sign on screen, then print or save as a PDF. Patient and owner details are never stored or sent anywhere.

Admission

Admission Details

(if known)

Client

Client's Details

Patient

Patient's Details

Treatment

Treatment Plan & Estimate

Resuscitation

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.

(e.g. cost cap for resuscitation, specific wishes)

Consent

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 signature
Staff signature
Preview

Hospital Admission and Treatment Consent Form

Live preview · prints exactly like this

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)
Email

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

Built by Dr Duncan Houston for Ask A Vet · askavet.com

Nothing typed into this form is sent to or stored by askavet.com. All data stays in your browser and leaves only in the PDF or printout you create. This template is general in nature. Check the consent and record-keeping requirements of your local veterinary regulator, and adapt the wording to your practice with your own adviser where needed.

Dr Duncan Houston
About the author

Dr Duncan Houston · BVSc, Veterinarian

Emergency careGeneral practiceMobile vet careFounder, ASK A VET™

Dr Duncan Houston is an Australian veterinarian with experience in emergency, general-practice and mobile veterinary care. He is the founder of ASK A VET™. This guide is educational and is not a substitute for hands-on veterinary care.

When Remember is on, this page saves your clinic's details in this browser only. Owner and patient details are never saved. It is never sent to Ask A Vet. Use Forget to remove them from this computer.