Authorization to Perform Procedure Form

Authorization to Perform Procedure Form

This form is optimized for mobile use, and requires a digital signature. It is best completed with a handheld device.
Please take a few moments to read through the following information and answer the appropriate questions so that we may best care for your pet. PLEASE NOTE: If you have more than one pet scheduled, this form will need to be completed for EACH pet.
Do you already have an appointment scheduled for your pet? *

Yes No

Appointment Information
Primary Owner's Name *

First Name Last Name
Secondary Owner's Name

First Name Last Name
Pet's Name [Hereafter referred to as PET] *
What date is your pet's appointment scheduled for? *

Month Day Year
Date
What procedure(s) are you authorizing for your pet? [Hereafter referred to as PROCEDURE] *
List any procedures we have discussed with you that you authorize

Microchip Information
Is your pet micro-chipped? *

Yes No I am unsure, please scan for a microchip
If your pet is not micro-chipped, would you like for us to microchip your pet while they are here for their PROCEDURE? The cost is $39.99 and includes both placing and registering the microchip.

Yes No

Westchase Veterinary Center Policies Policies

Please initial below each policy that you have read and agree.
Westchase Veterinary Center is a flea free environment. In order to maintain a healthy environment for all pets, I understand that if fleas are found on PET, they will be given flea treatment at my expense. *
Please type your initials
Due to limited storage space and health risks, we are unable to keep collars, leashes, toys, bedding, etc. I understand that if I choose to leave any of the above, I do so at my own risk and the item(s) may not be returned to me. *
Please type your initials
Westchase Veterinary Center is not a 24-hour facility. As such, pets left overnight are unattended during our closed hours. *
Please type your initials

Emergency Order
In the event of an unforseen emergency, we will attempt to reach you without delay. Please know that we take every precaution to ensure PET is safe and healthy enough to undergo PROCEDURE. Any known risks have been discussed with you. However, very rarely, medical emergencies do happen and we want to know your preference on how you would like for us to proceed. Please choose an option below.
In the event of a medical emergency with PET, would you like for Westchase Veterinary to begin to resuscitate and stabilize them? *

Yes, please resuscitate and stabilize PET No, please do NOT resuscitate and stabilize PET

Verification of Ownership and Procedure Authorization
I verify that I am the owner (or duly authorized agent for the owner) of the PET and authorize PROCEDURE to be performed by Westchase Veterinary Center. I authorize the use of anesthesia and other medications deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure as directed by the veterinarian.

I have been advised as to the nature of this procedure to be performed and the risks involved. No guarantees have been made regarding the outcome or cure. I understand that there is always a risk associated with any anesthesia episode, even in apparently healthy animals, and have discussed my concerns with the veterinarian. The veterinarian has provided me the opportunity to ask questions and receive answers regarding the procedure. This risk includes bodily injury or death. I understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated for the safety or care of PET. I hereby consent to and authorize the performace of such altered and/or additional procedures as are necessary in the veterinarian’s professional judgment. I accept responsibility for any result in additional charges.

I agree to be responsible for all charges incurred while PET is in the care of this facility and understand payment is due at the time my pet is released from the hospital. PET will receive pain medication prior to and after any procedure, treatment or surgery when pain or discomfort is anticipated or expected.
Signature *

Clear

Please contact us to schedule your pet's appointment.

You are receiving this message because you selected that your pet does not already have an appointment scheduled for a procedure. Please contact us for further help.
To contact us:

Phone: 813-818-0087

Text: 813-818-0087

Email: westchasevet@gmail.com

website: www.westchasevet.com

To contact us:

Phone: 813-818-0087

Text: 813-818-0087

Email: westchasevet@gmail.com

website: www.westchasevet.com
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