Kent Veterinary Center   ~  Judy Tubman, VMD

31239 Chesterville Bridge Rd.

Millington, MD 21651

Office: 410-928-5700   Fax: 410-928-3541



Hospital Admissions Form


Owner: ______________________________________________________________________


Address: _____________________________________________________________________


____________________________________________________________________________


Phone Number: _______________________________________________________________


Patient: ______________________________________________________________________


Species: ______________ Age: __________ Sex: ____________ Breed:__________________


Admission Date: ______________________________________________________________


Reason for visit: _______________________________________________________________



As owner, or duly authorized agent of the owner, of the above named animal, I hereby consent and authorize the clinic to receive, prescribe, treat or operate on this animal. I understand and agree with the terms and I am responsible for paying the bill for all services rendered.


All animals hospitalized at Centreville Equine must be fully vaccinated and free of parasites. The following are REQUIRED and must be up to date for hospitalization:


DOGS: Da2LPP-C vaccine, Bordetella vaccine, Rabies vaccine, and a negative fecal exam. Dogs more than one year of age must have a negative Heartworm test within a year.


CATS: Fvr-cp vaccine, Rabies vaccine, and a negative fecal exam.


NOTE: Any animal with fleas, ticks, or intestinal parasites will be treated immediately upon admission at the expense of the owner. Anything that is not current will be done at the time of admission. All animals due to undergo surgery must be in healthy condition, any animal with severe parasite infestation, that is severely under-weight, flea infested or in general poor health  will need to be treated and admitted at a later date, when surgery can be safely undertaken.


Our office is to use all reasonable precautions against injury, escape, or demise but will not be held liable or responsible in any manner regarding the care, treatment or safe keeping of the animal.  I understand that I am assuming all risks involved in care and treatment for this animal. I consent to administration of anesthesia as deemed necessary by the doctor. I acknowledge that risks and the possibility of complications exist in any surgical or medical treatment.


An estimate of anticipated fees has or will be given to me on request. A deposit is required upon admittance to the clinic. All charges shall be paid in full upon release. 4.0% of the total bill will be added to Mastercard & Visa payments.


All animals must be picked up within three (3) days of the specified release date. A written notice will be mailed to the address above. Five (5) days after such written notice, the animal will be considered abandoned and the clinic will take ownership of the pet. This will give the clinic the right to do with the pet what we deem appropriate. It is understood that abandonment does not relieve me from responsibility of payment for services rendered, including the cost of boarding.


I agree that in the case of nonpayment, a fee of 1.5% per month (18% per annum) & a $20.00 per month re-billing fee will be charged.  All collection and attorney fees necessary to collect this debt will be born by me.  Any disputes of a legal matter must be settled in Kent County, Maryland.  The signatory has read and is bound by this agreement.



SIGNATURE:


______________________________________________________________________


PHONE NUMBER FOR TODAY:


______________________________________________________


EMERGENCY PHONE NUMBER:


_____________________________________________________




Our Check Policy: Your check is welcome at our business. If your check is returned, it may be re-presented in an electronic manner. You hereby authorize service charges and processing fees, as permitted by law, to be debited from the same account by paper or electronically, at our option. Your payment by check shall be recognized as acceptance of our electronic check recovery system.