CHANGE OF OWNERSHIP. (Name of new owner) Of (Street) (City) (State) (Zip code) HOMEPHONE# WORK PHONE# I, (Name of PREVIOUS owner)

Transcription

1 CHANGE OF OWNERSHIP This is to certify that is now owned by (Name of Animal) (Name of new owner) Of (Street) (City) (State) (Zip code) HOMEPHONE# WORK PHONE# FAX# I, (Name of PREVIOUS owner) do hereby certify the change of ownership on (Date of change) ANIMAL'S NAME, IF CHANGED PREVIOUS OWNER'S SIGNATURE DATE PLEASE RETURN COMPLETED FORM TO: MEDICAL RECORDS DEPARTMENT NCSU COLLEGE OF VETERINARY MEDICINE 4700 HILLSBOROUGH STREET RALEIGH, NC TELEPHONE FAX

2 DISCHARGE AGAINST MEDICAL ADVICE I acknowledge and understand that I am removing this animal from the Veterinary Hospital against the advice of the Hospital. I hereby release the College of Veterinary Medicine at North Carolina State University, and all of its officers, agents, and/or employees from any and all responsibility for the care, treatment, condition, and custody of this animal. Owner or Agent Address Date Hour CVM Representative

3 NCSU College of Veterinary Medicine Veterinary Teaching Hospital EUTHANASIA CONSENT FORM Animal s full name: Hospital ID number: I, the undersigned, certify that I am the owner (or authorized agent of the owner) of the above animal. I unconditionally release this animal to the North Carolina State University Veterinary Teaching Hospital ( VTH ) as follows and authorize the VTH to euthanize this animal. I certify that this animal, to the best of my knowledge, has not bitten any person or animal during the last fifteen (15) days, nor has it been exposed to rabies. Please check the appropriate boxes below. [ ] If the animal is insured, the insurance company has been notified and permission has been granted for euthanasia. [ ] I request that a COMPLETE necropsy (autopsy) be performed. I understand that this provides the owners, clinicians, and pathologists an opportunity to learn as much as possible about this animal s illness and/or death. The information obtained from this animal s necropsy may improve the understanding of the cause, progression, and severity of this illness and may benefit other animals with similar disease(s). A complete necropsy involves careful and thorough analysis of all of this animal s organs/tissues. For this reason, cremation will be performed once the evaluation is complete. [ ] I request that a COSMETIC necropsy (autopsy) be performed. I understand that this does not allow for a complete study of all of this animal s tissues/organs. Samples of tissues/organs will be obtained that may provide a better understanding of this animal s illness and/or death. I have indicated below my wishes with regard to body care after the necropsy is complete. [ ] I DECLINE necropsy (autopsy) of this animal. I have indicated my wishes with regard to body care below. [ ] I elect COMMUNAL CREMATION of this animal s body. I understand that the ashes will not be returned to me. [ ] I elect PRIVATE CREMATION of this animal s body by a private cremation service. This animal s ashes will be returned to me. I will be charged for this service. The cremation service will call me at the provided phone number to make arrangements for payment and delivery of the remains. [ ] I elect to take this animal s body following euthanasia. [ ] I will pick up this animal s body within 48 hours. I understand that unless special arrangements are made, if I have not picked up this animal s body within 48 hours, this animal s body will be communally cremated, and the ashes will not be returned to me. [ ] I request that this animal s body be held for 24 hours while I make a decision regarding body care. [ ] I unconditionally donate the animal s body for teaching/research purposes. [ ] Special instructions: Owner/Agent / / Signature printed name date Clinician / / Signature printed name date Witness (verbal consent only) / / Signature printed name date For internal use only: NECROPSY REQUEST MUST BE SUMITTED THROUGH THE UVIS SYSTEM TO RECEIVE A NECROPSY REPORT. Clinician contact info (required): phone pager [ ] Check here if you would like for the pathology resident to a preliminary necropsy report.

4 INCOMPLETE RECORD ROUTING SLIP MEDICAL RECORD # CLINICIAN: ADMISSION DATE: PLEASE NOTE: If this record should be sent to another clinician, please write in their name and return this record to the completed record sorter. DO NOT place record in the other clinician's box. DEFICIENCIES FOR THIS RECORD: COMPLETION SIGNATURE Master Problem Case Summary Revisit Code Worksheet Discharge Instructions History Physical Special Exam Progress Notes ICU Flowsheets Clinician Orders Blood Transfusion Anesthesia Surgical Procedure Cardiology Reports Consultation Necropsy Surgical Pathology Pending Final

5 INFORMED CONSENT In order for the Veterinary Teaching Hospital (VTH) to further evaluate and treat the procedure(s) outlined below will be performed. The purpose of this form is to ensure that you understand the important facts associated with this procedure. Please read the information carefully. You are encouraged to ask questions until you are satisfied with the answers, both medical and financial. If you do not feel comfortable with the procedure(s) outlined, you may want to consider an alternative course of action. PROCEDURE(S): 1. I understand that complications can occur in spite of the best medical/surgical care. 2. I have been given the following procedure information sheet: 3. I have been informed of, and have discussed with the clinician, the risks and potential complications associated with the proposed diagnostic and treatment procedure(s). All of my questions have been answered to my satisfaction. 4. I have been informed of, and have discussed with the clinician, the alternatives available to the proposed diagnostic and treatment procedure(s). All of my questions have been answered to my satisfaction. 5. I have been informed that anesthesia or sedation may be administered for diagnostic and/or treatment procedure(s). I understand the risk of injury or death associated with anesthesia induction, positioning and recovery. Risk is greatest in large or medically compromised patients. 6. If an emergency situation arises and I cannot be contacted to provide authorization for treatment, the attending clinician should act in his or her best judgment, OR should not provide additional emergency treatment. I agree to pay the additional expenses incurred for the emergency treatment. 7. I have been informed that the initial cost estimate for the proposed diagnostic and treatment procedure(s) is $ (required deposit) to $. I agree to leave a deposit for the entire low end of the estimate at this time and pay the balance of the cost in full upon discharge of my animal. I understand that as the management of this case develops, additional treatment or course of action may be required and the cost may exceed the original estimate. I will be contacted at that time to authorize those changes and the additional charges associated with them, or to discontinue treatment. If additional treatment is authorized, I agree to make an additional deposit based upon the updated cost estimate. 8. I understand that under certain circumstances, additional samples such as blood, urine or tissue may be taken by my veterinarian during a diagnostic procedure to support studies on disease in animals. These procedures will only be performed if they do not pose additional risks to my animal or compromise their care as determined by my veterinarian. I will incur no cost associated with the procurement of these samples. I understand that I may be contacted at a later date to provide additional information on my animal that may be necessary for the studies being performed (strike through and initial if declined). I have read and fully understand all of the above. On the basis of the stated information, I consent to allow the VTH to hospitalize and to perform such services on my above referenced animal, and I agree to be responsible for the costs associated with all authorized services and treatment. (SEAL) Owner/Authorized Agent/Representative Signature Date Clinician Signature

6 COLLEGE OF VETERINARY MEDICINE QUICK TEST DISCHARGE INSTRUCTIONS Referring Veterinarian SENIOR CLINICIAN: ATTENDING CLINICIAN: STUDENT: REASON FOR VISIT: THE FOLLOWING PROCEDURES WERE PERFORMED TODAY / / : o Recheck Examination o Chemotherapy o Radiation therapy o Consultation o Fine Needle Aspirate o Urinalysis: Cystocentesis or Voided o Staple Removal/ Suture Removal o Thoracic Radiographs o Urine Culture o Bandage Change o BuffyCoat o CBC/ Panel o Biopsy o Bone Marrow Aspirate o Other: o Sedation o Abdominal Ultrasound PROBLEMS IDENTIFIED DURING THIS VISIT: YOUR PET RECEIVED THE FOLLOWING TREATMENT TODAY: RECOMMENDATIONS FOR FURTHER EVALUATIONS: Please call at least 2 weeks in advance in order to schedule an appointment that will accommodate the needs of your pet. If you have any questions or concerns, please call (919) Owner/Agent's Signature Clinician's Signature Student's Signature

7 RELEASE OF INFORMATION I, owner of, hereby authorize (Name of owner/owners) (Name of animal) North Carolina State University's Veterinary Teaching Hospital to release information, medical records or a summary of my animal's medical record from his/her visit on: (Approximate date(s) Please send to: Myself Other: Name Street or P.O. Box City State Zip Code Purpose of this information: The Veterinary Teaching Hospital, its employees and officers, and the attending clinician are released from legal responsibility or liability for the release of this information to the extent indicated and authorized herein. Owners signature Date Co-owner's signature Date PLEASE RETURN SIGNED AND COMPLETED FORM TO: Medical Records Department NCSU College of Veterinary Medicine Veterinary Teaching Hospital 4700 Hillsborough Street Raleigh, NC Telephone FAX