General Procedure Consent Form- NR or WAC

Please select at which facility your pet is undergoing their procedure:*

New Richmond

Today's Date*

Date

Owner's Name*

First NameLast Name

Best Contact Number for Today*

Area CodePhone Number

Secondary Contact Number

Area CodePhone Number

Do you prefer a phone call or text message in the event we have questions during the procedure and for Dr. Miller's post-procedure update?*

Phone CallText MessageNo Preference

Patient Name*

Species*

DogCat

Age*

Sex*

Male IntactMale NeuteredFemale IntactFemale Spayed

Does your pet have any known allergies?*

YesNo

If your pet has known allergies please list them below (food, medications, anesthesia, vaccines, etc.).

Please confirm your pet has not had any food or snacks since before midnight last night (the night before the procedure, a very small amount of water is ok).*

My pet has not had any food or snacks.My pet ate this morning.

Is your pet doing well at home or do you have any concerns we should be aware of before the procedure today? (Select all that apply)*

My pet is doing well and I do not have any concerns.My pet has experienced vomiting/diarrhea/coughing/sneezing (any or all) within the last several days.My pet has been lethargic/appetite is off/ water intake is off (any or all) within the last several days.My pet is experiencing other symptoms not listed above that I would like Dr. Miller to address today.

Please list your pet's current medications and supplements below, their dosages, the frequency you give them, and when they received their last dose. If they are not on any current medications please type in "N/A" or "no medications" below.*

I hereby consent and authorize Lifetime Pet Center of New Richmond to prescribe for, treat, or operate upon my pet (listed above). I have been advised of the risks associated with treatments and/or surgery. It is thoroughly understood that I assume all risks and will take responsibility for payment of services rendered. Please sign your initials in the space below to acknowledge the above.*

The Lifetime Pet Center of New Richmond will use all reasonable precautions against injury, theft, escape, or destruction of the animal(s) listed above, but will not be held responsible in any manner whatsoever on account of the care, treatment, or safekeeping of the animal(s) above described, as long as acceptable standards of veterinary medicine have been followed. Please sign your initials in the space below to acknowledge the above.*

It is also noted that my pet will be vaccinated if medically neccessary or if recommended by the prescribing doctor in order to protect the safety of my pet and the staff handling my pet. Please note that rabies vaccination is required by county law. In addition, if my pet is found to have fleas or other parasites while in the hospital, s/he will be treated accordingly as seen fit by the doctor and staff. Please notify us if your pet has any allergies or drug sensitivities. Please sign your initials in the space below to acknowledge the above.*

After reading the above, I have signed to acknowledge receipt and understanding.*

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Your pet is undergoing surgery/having a procedure today. We may discover additional conditions about your pet while s/he is with us, which can incur additional charges. Please indicate how you would like us to handle these situations should they occur:*

Do the procedure regardless of cost.Call with an estimate for additional charges. If we are unable to reach you we may perform the procedure.Call with an estimate for additional charges. If we are unable to reach you we may not perform the procedure.

Your pet may need to-go-home pain medications after the procedure. Please select your preference below (species dependent):*

Dogs- Loxicom oral liquid given once daily for three days after the procedure. $15.50Dogs- Galliprant chewable tablets given once daily for three days after the procedure. $15.28 to $25.60Cats- Onsior chewable tablets given once daily for three days after procedure. $24.90Cats- Zorbium topical solution applied in-house by a staff member prior to discharge. Provides three days of pain control at home. $40.78 to $57.80

Additional Procedures/ treatments that we can perform while your pet is with us today: (Can select multiple)*

Diagnostic Lab work- Comprehensive Profile/ Thyroid Panel/ Fecal Exam for Parasites/ Urinalysis, ETC. (Estimate can be provided, alert staff to your specific request or questions regarding diagnostics)Update Due Vaccines (Written proof of rabies is REQUIRED for all pets.)Microchip Placement (Includes lifetime registration, no additional fees) $64.50Additional Pain Control with Nocita, a 4 day nerve block $245.00IV Fluids (REQUIRED for all pets of 6 years of age and older, or any pets with additional health concerns. Longer procedures also require IV fluid therapy and support.) $65.56Toenail Trim (No charge with anesthesia)Ear Cleaning $26.50No Additional Services (unless required)

Please note: blood work may be required for your pet. If an estimate is requested the required blood work will be on the estimate.

Would you like an estimate for today's procedure (if you haven't already been provided one)?*

YesNoI already have an estimate.

Please provide an email address if you would like an estimate.

example@example.com

By signing below, you acknowledge the estimate (if requested) for the procedure is not a guaranteed price for services. There are often unforeseen circumstances that could result in an increased cost for the procedure we are performing today. We will make a reasonable effort to inform you and gain consent for additional services before proceeding, barring a life saving emergency. If you have any questions or concerns please speak with a staff member before your pet's procedure.

Signature*

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