Shaffer Animal Hospital - Anesthesia/Sedation Authorization

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Owner and Pet details* This field is required.
First Name
Last Name
Phone Number
Email Address
Pet Name
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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/sedation 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 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
Should unexpected life-saving emergency care be required and the hospital staff is unable to reach you, do you agree for Shaffer Animal Hospital to provide such treatment and 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.
Clear
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/sedation.
I would not like my pet to be microchipped while under anesthesia/sedation, or my pet has already been microchipped.
8
Spay/Neuter Tattoo:
We highly recommend the application of a complimentary sterilization tattoo with your pet's spay/neuter procedure. The tattoo is applied adjacent to the spay/neuter incision, is made with green ink, and will measure no more than 0.5 inch in length. This small tattoo allows veterinary professionals to clearly indicate your pet has been spayed/neutered thus reducing the risk of unnecessary future surgeries if your pet were ever to become lost.

I authorize the recommended sterilization tattoo at no additional charge
I do not authorize the recommended sterilization tattoo, or my pet is not being spayed or neutered today. *
9
Spay/Neuter Tattoo:We highly recommend the application of a complimentary sterilization tattoo with your pet's spay/neuter procedure. The tattoo is applied adjacent to the spay/neuter incision, is made with green ink, and will measure no more than 0.5 inch in length. This small tattoo allows veterinary professionals to clearly indicate your pet has been spayed/neutered thus reducing the risk of unnecessary future surgeries if your pet were ever to become lost.
I authorize the recommended sterilization tattoo at no additional charge
I do not authorize the recommended sterilization tattoo, or my pet is not being spayed or neutered today.
10
Date of Appointment* This field is required.
Date
Month
Day
Year
11
We would like to notify you after your pet's surgery on their recovery. Would you prefer to be called, texted, or notified through our app?
Call
Notified Through App
Text
12
If Call
Please list number for medical decisions
Please list number for drop-off & pick-up, if different
13
If Text
Please list number for medical decisions
Please list number to text if drop off and pick-up are different
14
If App, Please list name in account
15
Cancellation/No-Show Policy For Surgical Procedures:

In our commitment to ensuring the optimal health and safety of your beloved pet, we have established a policy regarding cancellations within 24 hours of scheduled anesthesia procedures or non-arrival on the designated day.

For any cancellations falling within this timeframe or instances of non-arrival, a rescheduling fee of $100 will be applicable to the procedure performed. This measure is imperative for maintaining operational efficiency and upholding the standard of care for all patients under our supervision.

Please note that if you have an appointment with one of our traveling specialists (Dr. Borde or Dr. Myers), they maintain their own cancellation policies.
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I have read and understand the nature of the above procedures and give my consent to proceed as set forth herein.
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Signature * This field is required.
Clear
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Today's Date* This field is required.
Date
Month
Day
Year
Should be Empty: