Poland Veterinary Centre

6609 Clingan Rd.
Poland, OH 44514

(330)757-8868

www.polandvet.com

Authorization for Hospitalization/Treatment

I have discussed the reasons for hospitalization /treatment with Drs. Daugherty, McMurray, Wolfe and/or Preston, and I am satisfied with the plan of treatment. The nature of such services has been described to me to my satisfaction, and I realize that neither guarantee nor warranty can ethically or professionally be made regarding the results or cure.

If anesthesia or sedation is required, I understand there are inherent risks, including death. I authorize the staff to complete emergency procedures necessary for the well-being of my pet until communication with me is possible. 

Estimated fees were explained to me, and I understand there is a range of cost for anticipated services. I understand unforeseen complications are possible, and further treatment might be necessary during hospitalization. I accept full financial responsibility for any and all services rendered and agree to pay all fees incurred, in full, at the time of discharge from the hospital. 


spacer
Authorization for Hospitalization/Treatment
spacer*Procedure
spacer*Procedure date
spacer*Client name
spacer*Pet name
spacer*Contact phone number(s) for procedure day
spacer*Please initial: I have discussed the reasons for hospitalization /treatment with Drs. Daugherty, McMurray, Wolfe and/or Preston, and I am satisfied with the plan of treatment.
spacer*Please initial: The nature of such services has been described to me to my satisfaction, and I realize that neither guarantee nor warranty can ethically or professionally be made regarding the results or cure.
spacer*Please initial: If anesthesia or sedation is required, I understand there are inherent risks, including death. I authorize the staff to complete emergency procedures necessary for the well-being of my pet until communication with me is possible.
spacer*Please initial: Estimated fees were explained to me, and I understand there is a range of cost for anticipated services. I understand unforeseen complications are possible, and further treatment might be necessary during hospitalization.
spacer*Please initial: I accept full financial responsibility for any and all services rendered and agree to pay all fees incurred, in full, at the time of discharge from the hospital.
spacer*E-signature and date
Check the reCAPTCHA to
ensure you are not a robot :
spacer