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Parasite Prevalence – Westchester County
Admissions Client Form
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Pet Owner & Pet Information
Please check any and all symptoms your pet may be having:
Trouble Eating or Drinking
Itchy Skin and/or Ears
Blood in Urine or Stool
Hair Loss on Body
Please list any additional concerns you have about your pet or elaborate on the checked symptoms:
How long have you noticed the above?
In order to prevent the spread of contagious diseases, ALL patients admitted to our hospital must be current on vaccines and free of internal & external parasites. If your pet does not meet our admission requirements, they WILL be immunized and/or treated as necessary and a fee will be charged for the additional services not included in this estimate. BY LAW: ALL PETS MUST HAVE THE RABIES VACCINATION TO RECEIVE ANY SERVICES AND A PHYSICAL EXAM IS REQUIRED TO ADMINISTER THE VACCINE. All pets will receive a thorough physical exam. Some procedures may require sedation and blood work may be recommended first if your pet is over 7 years. Pets requiring full anesthesia WILL have blood work run that is specifically tailored to their health and needs. Although all anesthetic procedures carry some degree of risk, and blood work cannot detect every abnormality, it is important to get a complete picture of their current health status so that we may reduce the likelihood of anesthetic complications. Please provide signature below to indicate you understand and agree.
I authorize Valhalla Animal Hospital to perform the following procedure(s) on my pet*:
Annual Exam and Vaccines
Diagnostics (Blood Work/ Radiography/ Ultrasound/ Other Tests)
Hospitalization/ Monitoring Services/ ER Transfers
If you chose 'Other Service(s)', please detail the service below.*
Cardiopulmonary Resuscitation (CPR)
In the event of a life-threatening situation, we will try every means to reach you to discuss the events that are transpiring. However, during this time, we need to know what your thoughts are on life saving measures for your pet. YES, I authorize appropriate life saving measures in the case that my pet suffers from cardiac or pulmonary arrest. I understand that if such measures are necessary that the cost of the services may exceed my estimate. NO, I do not wish these life saving measures to be employed should my pet be undergoing cardiac or pulmonary arrest. At this time, I am electing for a “Do Not Resuscitate” status for my pet. Please provide owner signature below to indicate you understand and agree.
Yes to CPR
No to CPR
Payment is required when services are rendered. We accept all major credit cards, personal checks (those in good standing and with proper identification) as well as third-party financing. A deposit of 75% of the estimated charges is required upon admission and the balance will be due at time of pick up. **Please be Advised** The provided estimate is just an approximation of the final cost. The final invoice may be lower OR higher than the estimate provided. We will make every attempt to inform you as we approach the upper limit of the estimate OR exceed it. At that point we will request an additional deposit. Please do not hesitate to ask for an estimate update at any time.
I give permission to Valhalla Animal Hospital to perform diagnostic, surgical and medical treatment as deemed advisable. I understand that procedures of diagnosis, surgery and medical treatment will be discussed with me before proceeding, except in emergency situations. In many cases it is impossible to determine in advance the extent of surgical and/or medical treatment required. I agree to make prompt and complete payment upon discharge of the pet listed. I understand that if I neglect to pick up of the animal listed with five (5) days of notification to the above address that said animal will be considered abandoned and may be surrendered to a rescue, or humanely euthanized, as deemed best for the animal. Doing so does not relieve me of my financial obligations. I further understand that in case of non-payment, I will be subject to billing and finance charges. I realize that neither a guarantee nor warranty can ethically or professionally be made regarding results or cures. I understand the risk associated with anesthesia. I assume all financial responsibility for services rendered and understand that full payment is due upon release of my pet. I have read and fully understand all the above terms regarding my pet.
This field is for validation purposes and should be left unchanged.