Concierge Form and Treatment Authorization in Fairfax, VA

Client Name:

Patient Name:

Today’s Phone Number:

Reason for Admission/Procedures to be performed:

Client Questionnaire:

Year-round flea/tick/heartworm prevention is recommended.

Please provide information about how your pet has been doing and describe any concerns

List current medications, including supplements, and when last dose was given

Medication	Date Of Last Dose

Does your pet have preventatives?

Yes
No

Please list current diet/food name:

Have you noticed any changes in behavior?

Yes
No

If yes, please explain:

Have you noticed any coughing or sneezing?

Yes
No

If yes, please explain:

Have you noticed any changes in drinking, urination or in appetite?

Yes
No

If yes, please explain:

Has your pet experienced any vomiting or diarrhea in the past 24 hours?

Yes
No

If yes, please explain:

I, the undersigned owner, authorized agent of the owner or Good Samaritan responsible for seeking veterinary care for the pet identified above, certify that I am over eighteen years of age, and hereby consent to the examination of this pet by staff veterinarians at Fairfax Veterinary Hospital. I also agree that after consultation with me, the hospital’s doctors may prescribe medication for, treat, hospitalize, sedate, anesthetize and/or perform surgery on this animal. I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure is initiated. Should some unexpected life-saving emergency care be required, and the attending veterinarian be unable to reach me, this practice’s staff has my permission to provide such treatment and I agree to pay for all related fees. I accept that veterinary medicine is an inexact science and that no guarantee of successful treatment has been made.

I understand that an estimate of the costs for veterinary services will be provided to me and that I am encouraged to discuss all fees attendant to such care before services are rendered and during this pet's ongoing medical treatment. If this animal is hospitalized, I agree to pay for the balance of all services rendered on a cash, credit card or check basis at the time the pet is discharged from the hospital. In the event the pet is hospitalized for more than twenty-four hours and the attending doctor is unable to reach me, I understand it is my responsibility to call the hospital at least every twenty-four hours to inquire as to the medical status of my pet and the fees incurred for medical services up to that day. In the event of an open balance, I agree to make a monthly payment including a financing fee equal to 2% of the unpaid balance.

I further agree that either I, or an authorized agent of mine, will pick up this pet and pay for all accrued charges within five days after receiving written or oral notification that this animal is ready to be released from the hospital. Such notice will be given at the address maintained on the hospital's patient/client record. I agree that if I fail to comply with this policy, this practice may handle this abandonment in the best interests of the pet and the Hospital, and I will be responsible for all fees incurred.

Client Signature

(I acknowledge that by typing my name above, this will be considered a signed consent to the above procedures)

Date