Shaffer Animal Hospital - Anesthesia Authorization

1

Owner and Pet details* This field is required.

Date

First Name

Last Name

Email Address

Pet Name

2

Owner's Consent* This field is required.I am the owner of the above-named animal or am responsible for it and have authority to execute this consent. I hereby authorize Shaffer Animal Hospital to perform the above procedure(s). I hereby also authorize the use of such anesthetics as you see advisable and performance of such surgical or therapeutic procedures as you determine to be indicated. I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. My signature of this form indicates that any questions I have regarding the following issues have been answered to my satisfaction: · The reasonable medical and/or surgical treatment options for my pet · Sufficient details of the procedures to understand what will be performed · How fully my pet will recover and how long it will take · The most common and serious complications · The length and type of follow-up care and home restraint required · The estimate of the fees for all services · Any necessary payment arrangements I understand that if I pick up my pet any later than the posted time of closure of the business, I may be subject to a late fee of $10 per 15 minutes. While I accept that all procedures will be performed to the best of the abilities of SAH, I understand that veterinary medicine is not an exact science and that no guarantee or warranty has been made regarding the results that may be achieved. I agree to indemnify and hold harmless from and against any and all liability arising out of the performance of any procedures referred to above. I agree to pay a deposit of 50% of the estimated fees, assume financial responsibility for the remaining fees due on the date of discharge, and provide payment via cash, accepted credit cards, Scratchpay, or check at the end time my pet is discharged from the hospital. Should unexpected life-saving emergency care be required, and the hospital staff is unable to reach me, the staff has my permission to provide such treatment and I agree to pay for such services.

3

If hospital staff is unable to reach you, does it has the permission to provide such treatment and do you agree to pay for such services.* This field is required.

Yes

No

4

Please list the procedure to be performed/condition.* This field is required.

5

Please Specify

I would like an estimate of charges for the above procedure(s).

I would not like an estimate of charges for the above procedure(s).

I have received an estimate of charges; please contact me with an estimate if any additional services are needed.

6

My pet did not have food after 10pm the night before* This field is required.

ClearSignature

7

We are pleased to offer the Home Again Retrieval System to permanently identify your pet in the event that it should become lost. We will register your pet’s information for you and you will be responsible for keeping your contact information current with Home Again.

I would like my pet to be microchipped while under anesthesia.

I would not like my pet to be microchipped while under anesthesia.

8

Date of Appointment* This field is required.

Date

9

We would like to notify you after your pet’s surgery on their recovery. Would you prefer to be called or notified through our app?

Call

Notified Through App

10

If Call, Please list number

11

If App, Please list name in account

12

I have read and understand the nature of the above procedures and give my consent to proceed as set forth herein.

13

Signature * This field is required.

Clear

14

Date* This field is required.

Date