Client Consent Form | Cypress St. Animal Hospital

Address -1889 Cornwall Ave Vancouver, BC V6J 1C6, Canada
Contact Us - +1 (604) 734-2500
Email ID - cypresshospital@gmail.com

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New Client Registration

Please fill the form to get a call back from us or talk over the email .

Owner's Name:

Co-Owner/Spouse/Relative's Name:

Address:

City:

Postal Code:

Home Phone:

Cell Phone:

Co-owner phone

Email:

Previous Veterinary Hospital

Does your pet have any known allergies?

Do you have pet insurance?

Insurance Company

Policy/ Customer #

#1 Pet's Name

Species

Breed

Colour

Sex

Female Male

Spay OR Neuter

Yes No

Date Of Birth

Vaccines up to date?

Yes No

General health ?

#2 Pet's Name

Species

Cat Dog Other

Breed

Colour

Sex

Female Male

Spay OR Neuter

Yes No

Date Of Birth

Vaccines up to date?

Yes No

General health ?

#3 Pet's Name

Species

Cat Dog Other

Breed

Colour

Sex

Female Male

Spay OR Neuter

Yes No

Date Of Birth

Vaccines up to date?

Yes No

General health ?

I hereby acknowledge and agree to the terms and conditions set forth. By signing below, I confirm my acceptance and understanding of these terms.
A DEPOSIT MAY BE REQUIRED, AND FINAL BILLS ARE UPON RELEASE OF THE PATIENT. NO BILLING OR PAYMENTS PLANS.

Date

Signature Of Owner

New Client Registration

Please fill the form to get a call back from us or talk over the email .

Owner's Name

Email Id

Pet's Name

Pet's Age

Species

Sex

Weight

NPO

ADD

Nailtrim Microchip Anal Gland Expression

Misc

Blood Work

Done Accept Decline

Sedation (If Needed)

Accept Decline

Meds to go Home

Accept Decline

Estimate

Initials

I am the owner or agent of above pet. I have authority to execute this consent and am over the age of 18.

I hereby authorize and direct the veterinarians at Cypress Street Animal Hospital to perform the above described procedure(s). The nature and purpose of the procedure(s) has been explained to me and I understand that no guarantee exists as to the result of diagnosis and treatment of the said animal. I also understand that there is no one at the hospital during the night time.

I take full responsibility for the DECLINED tests and treatments and I take full financial responsibility for the animal. I understand that anesthesia/surgery always carry potential risks

I have been informed that in case my dog/cat is obese or in heat during the procedure, it may involve potential risk and will have an additional procedure cost charged around $60-$90.

I have had the fees outlined to me and agree to pay all such fees and charges at the time of discharge.

I agree to pay, in full, for services rendered, including those deemed necessary for medical or surgical complications or unforeseen circumstances. If unforeseen conditions arise, in the judgment of the attending veterinarian, call for procedures or treatments other than those now being authorized. I authorize such procedures if reasonable efforts to contact me for further consent are unsuccessful.

I understand that if an animal is not picked up within 5 days of the scheduled pick up time, the clinic will contact the SPCA and your pet will be surrendered to the SPA or City pound, which will take over ownership of the pet.

I have read and understand this consent.

Signature of the Owner/Agent

Phone Number

Other Notes

Signature of Owner/Agent

Company

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cypresshospital@gmail.com

+1 (604) 734-2500

Hospital Timings

Mon to Fri 9:00 AM - 8:00 PM
Sat - Sun 9:00 AM - 8:00 PM
STAT 9:00 AM - 6:00 PM

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