Blood Glucose Drop off

please complete the form below

    CLIENT INFORMATION

    PET INFORMATION

    Name (required)

    Species
    CanineFelineOther

    Breed (required)

    Color

    Age (required)

    Sex

    What type of food are you feeding your pet?

    When was the last time your pet ate? (required)

    How much did they eat?

    What insulin is your pet receiving?

    How much insulin (in Units) is your pet receiving?

    Please describe how you administer the insulin?

    When did you last give insulin to your pet?

    How is your pet’s:

    Appetite
    Increaseddecreasedsame
    Urination
    Increaseddecreasedsame

    Is your pet experiencing any weight loss?
    If yes, please describe
    NoYes

    What is the best phone number you can be reached at today?

    CONSENT & AUTHORIZATION FOR LIFE SAVING TREATMENTS
    Please select one of the following:

    In the unfortunate event that your pet experiences a cardiopulmonary arrest (his/her heart stops or he/she stops breathing on their own), we at FRVH need to know you and your family’s wishes on how you would like us to respond. Some families choose for us to pursue CPR (cardiopulmonary resuscitation) in an attempt to re-establish your pet’s heartbeat. Due to many understandable circumstances, some families ask that CPR is not pursued, designating their pet at DNR (do not resuscitate). Please know that we support and respect your family’s decision regardless of your reasoning.

    Please select one of the following:

    I wish to select CPR, including chest compressions and manual ventilation. I acknowledge the risks associated with CPR and consent to the initial resuscitation charges of $500-1000, knowing this total may substantially increase if extensive intervention is needed to recover my pet.I wish to select DNR, acknowledging that no life-saving measures will be deployed should my pet’s heartbeat or breathing capabilities stop.

    CONSENT

    I am over 18 years of age and am the authorized owner and/or guardian for the aforementioned patient. I authorize Folsom Ranch Veterinary Hospital and Urgent Care (FRVH) to perform treatment/procedure(s) on my pet(s) as recommended by FRVH's Veterinarians and employees. I was informed of the reasons for the treatment/procedure(s), along with the expected benefits and risks involved. I confirm that by signing below, I understand the inheritable and sometimes unforeseen risks associated with veterinary care and release all liability, without exceptions, from Folsom Ranch Veterinary Hospital (FRVH) while treating my pet(s). I understand that payment is required for all services at the time they are rendered unless prior arrangements have been made with hospital management. I understand that deposits may be required prior to certain procedures. In the event that a refund is due and the original payment is a credit card, the refund will be posted against the original credit card. I also authorize FRVH to use pictures of my pet(s) for learning or marketing purposes. Consent will apply to all future pets added to this account unless and until I provide a written revocation of that consent.

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