Arms of Aloha: Hospice, Pain Management, and End-of-Life Care for Pets

808-435-3006

PO Box 342999

Kailua, HI 96734

info@armsofaloha.com

Today’s Date: ________________

Your Information:

Name of primary contact:____________________________________________

Driver’s License or I. D. Card Number*: __________________  Type of ID: ______________

Occupation: ____________________  Employer:____________________________________

Primary email address to use for correspondence with us:_______________________________

Telephone Numbers (please include area code):  

     

H:(____)_____-______

  W:(____)_____-_______

Cl:(____)_____-_______

Alternate Contact:

________________________________________________________________

                   Name                                                                                  Phone(s) and/or email

[ ]  Spouse  [ ]  Partner  [ ]   Co-owner  [ ]

Address (if different than above):_____________________________________________

Occupation: ____________________  Employer:____________________________________

Other people important to your pet, and their relationship to him or her:


Other Providers

                                                                           

Other veterinarian(s) /clinic(s) (if applicable):_________________________________________

Please send records and updates to my regular clinic(s) ☐

Please invite the following providers to collaborate in my pet’s care:__________________________________________________________________

Is there someone we may thank for their referral?_______________________________

                                     

Authorization for Hospice Care Treatment

Pet’s Name: __________________  Client’s Name (Please Print):______________________

I certify I am the legal owner/authorized agent for the owner of the companion animal described above and give Arms of Aloha LLC, and any authorized agents, staff, or representatives full and complete authority to examine, prescribe for and/or treat (“hospice care”) the above-described companion animal. I agree Arms of Aloha LLC, and any authorized agents, staff, or representatives shall not be liable for any direct, indirect, or consequential damages resulting from such hospice care.

I understand hospice care is focused on preserving quality of life for as long as possible and is NOT focused on curing medical conditions or providing routine veterinary care, surgical care and/or emergency treatment/transport. Arms of Aloha LLC has informed me if additional diagnostics, procedures and/or more aggressive hospice care are recommended for my companion animal at this time, and I have (check one):

        ______ Declined additional diagnostics, procedures and/or more aggressive hospice care.

        OR

______ Accepted the recommendation(s), and Arms of Aloha LLC has made the necessary referrals

Payment of Fees

Payment is due at the time of service. We accept all major credit cards and cash. We regret that we cannot take personal checks.

It is understood that an estimate of charges will be given for services. No guarantee or assurance can be made as to the results that may be obtained. Further, I assume full financial responsibility for all charges incurred by my pet. I realize that these charges may exceed a given estimate if complications arise.

I assume full responsibility for the actions of the companion animal described above and all charges incurred during his/her hospice care. I also understand all professional fees are due at the time hospice care rendered. Initial________

Off-Label Medications

I understand that, in many cases, there is no medication which has gone through the FDA approval process to treat a particular problem in a particular species/type of animal.

I understand that, in those situations, the FDA allows veterinarians to use a medication which is approved for another disease, animal, or purpose. This is called "extra-label" use, because the drug is being used for "extra" uses beyond what is on the label.

Carolyn Naun, D.V.M. at Arms of Aloha, LLC may need to prescribe medications to my pet in an extra-label fashion. When the doctor does this, I understand that she will be following the guidelines set forth by the FDA, using the best available information about the safety and effectiveness of the treatment protocol. I understand that I have the right to ask if any drug prescribed to my pet is being used in an extra-label fashion, and to be informed of the risks and benefits of such treatment. Initial______

I have carefully read and fully understand the above provisions.

Signature: _________________________   Date:____________  


Photography and Information Release

I understand that by retaining the services of Arms of Aloha, LLC, I consent to have my pet’s photograph and medical case information used for educational purposes in any manner and medium. Identifying information (including dates, location, name, or other distinctive characteristics) will be changed or omitted for privacy unless I explicitly agree in writing otherwise. (Please initial)______

(Optional) I hereby grant to Arms of Aloha LLC, the irrevocable and unrestricted right to use and publish photographs of my pet, or in which he/she may be included, for editorial, education, trade, advertising and any other purpose and in any manner and medium; to alter the same without restrictions; and to copyright the same. My pet’s name, but not my name or surname, may be used in conjunction with said photographs. I hereby release Carolyn Naun, DVM and Arms of Aloha LLC from all claims and liability relating to said photographs.

EXCEPTIONS: I do not authorize Arms of Aloha to use my pet’s photo or name for the following:

Signature_____________________________________   Date:__________


Authorization to Share Medical Records

Clinic(s):______________________________________________________________________

Patient’s Name:_______________________

Owner’s Name(s):___________________________________________________

Please send a copy of the following records to Arms of Aloha LLC:

This authorization is valid until (indefinite if left blank):______________

______________________________________________________________________

Signature                                            Print Name                                      Date

Clinic Staff:

You may send records by the method most convenient to you:

Email:  info@armsofaloha.com

Fax:  808-435-3006

Mail: PO Box 342099, Kailua, HI 96734

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