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 and accept that there are inherent risks, including death. I also authorize the Poland Veterinary Centre staff, in an emergency situation, to follow-through with such procedures as are necessary for the well-being of my pet on a continuing basis, until communication with me is possible. 

I have also had estimated fees explained to me and understand there is a range of cost for anticipated medical services. I understand there might be unforeseen complications and that further treatment might be necessary during hospitalization. I accept and assume full and total financial responsibility for any and all services rendered in the treatment of the below described patient and agree to pay all fees incurred, in full, at the time of discharge from the hospital. 


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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 authorize the use of sedatives and pain medication as deemed necessary by any of the doctors.
spacer*Please initial: I understand I received an estimate, and there might be unforeseen treatment necessary during hospitalization. I accept total financial responsibility and agree to pay in full at the time of discharge from the hospital.
spacer*E-signature and date
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