Hospitalisation and Diagnosis Admission Form

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Hospitalisation and Diagnosis Admission Form

Please complete the form in full.

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Preferred Clinic for Admission *

Clonakilty
Bandon

Please select the clinic where you wish to have your pet admitted.

Pet Name

Breed

Neutered

Weight

*In Kgs

Microchip No.

Sex

Age

Insurance Company

Patient ID

Owners Details

Full Name

First

Last

Email Address

Phone Number

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Please indicate preferred option for patient updates/discharge information

Consent Statement 1 *

I hereby give permission for the admission of the above name pet to Faxbridge Veterinary for hospitalisation and diagnostics

I consent to the following while my pet is hospitalised:

Full Blood Tests – Canine/Feline – €106.5
Canine CPL – €66
Feline FeLV/FIV Test – €49.50
Overnight Hospitalisation + Food – €40-45
Ultrasound (In-House) – €55
X-Rays
Fluid Therapy
Sedation / Anesthesia
Additional Procedures

Consent Statement 2 *

I understand that all sedation and anesthetic procedures carry a risk and that the staff at Faxbridge Veterinary will take all the precautions necessary to reduce those risks at all times.

Consent Statement 3 *

I agree to settle my entire account on collection of my pet. I understand that Faxbridge Veterinary does not provide any credit unless arranged in special circumstances with the manager or treating vet.

Consent Statement 3 (copy) *

I agree to settle my entire account on collection of my pet. I understand that Faxbridge Veterinary does not provide any credit unless arranged in special circumstances with the manager or treating vet.

Consent for Photography and Social Media Use *

Yes, I give my consent
No, I do not give my consent

I give permission for Faxbridge Veterinary to take photographs and/or video recordings of my pet while under their care, and to use these images for promotional purposes, including but not limited to social media platforms.

Signature *

Clear Signature

Insurance Please preferred

Date *

Opening Hours

Clonakilty
Mon-Fri: 9am-6pm
Sat: 9am-1pm
T: 023 88 33252

Bandon
Mon-Fri: 9am-6pm
Sat: 9am-1pm
T: 023 88 41842

24/7 Emergency Services
T: 023 88 33252

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