Bridger Veterinary Hospital
3104 Green Meadow Drive
Helena, MT 59602
406-443-5874
Hospitalization Consent Form
PATIENT'S NAME OWNER'S NAME
DATE
PHONE (where we can reach you today)
PROCEDURE(S):
PHYSCIAL EXAM
ANNUAL VACCINATIONS
HOSPITALIZATIONS (including IV fluids, medications, or other treatments if necessary)
Sedation (if necessary)
OTHER:
As with all proper physical examinations certain symptoms, problems, and ages may indicate some of the following diagnostic
and therapeutic options. Accepting the following items means that these procedures will only be performed if deemed
necessary by the veterinarian to aid in diagnosis.
PROCEDURE: REASON: ACCEPT DECLINE
Hospitalization To enable the veterinarian to properly monitor
the patient and to enable the patient to receive
appropriate treatment. This also includes the
possibility of IV fluids, medications, & other
treatments.
Blood Work
To check organ functions, the oxygen
carrying ability of blood, ability to fight
infection, platelets for proper clotting and to
establish a baseline for future references.
X-Rays
Visibility of possible fractures, arthritis, joint
problems, masses and the size and shape of
internal organs.
I understand that during the performance of the foregoing procedures, unforeseen conditions may be revealed that necessitates extension of the forgoing
procedures or different procedures than those set forth above. Therefore, I hereby consent and authorize the performance of such procedures as are
necessary and desirable in the exercise of the veterinarian's professional judgment. I also authorize the use of appropriate anesthetics, and other
medications, and I understand that the hospital support personnel will be employed as deemed necessary by the veterinarian. I have been advised as to the
nature of the procedures and risks involved. I realize that results cannot be guaranteed.
CPR means “Cardio Pulmonary Resuscitation” and is the treatment (resuscitation) of a pet who has stopped breathing or
whose heart has stopped beating. Resuscitation of a pet who has stopped breathing but still has a heartbeat is more likely to
succeed than resuscitation of a pet with no heartbeat.
IN THE EVENT OF A MEDICAL CRISIS I wish for the doctors of Bridger Veterinary Hospital to perform CPR on my pet if he/she
suffers respiratory or cardiac arrest. I understand that my pet may or may not respond to this life-saving procedure. I understand
that if my pet survives because of CPR, he/she may have permanent health issues. CPR may cost up to $300.00
I DO NOT want CPR performed on my pet. I understand that if my pet stops breathing, and/or his/her heart stops beating, that
my pet will die. I elect to have DNR orders placed on my pet’s record for his/her stay.
PLEASE INITIAL ONE:
SIGNATURE DATE
DNR means “Do Not Resuscitate.” This means that if a pet stops breathing or his/her heart stops, no effort will be made to
attempt to revive the pet, and the pet will die.
I have read and understand this authorization and consent. I also realize that I am responsible for the FULL payment when my animal is release from the care
of Bridger Veterinary Hospital.