Authorization form for Veterinary Care and/or Surgical Procedure

GREATER ANNAPOLIS VETERINARY HOSPITAL

Authorization for Veterinary Care and/or Surgical Procedure
DATE OF PROCEDURE (may not be current date)

MonthDayYear
Date
Owner:*
Pet:*
PID (if known):
Client ID (if known):
Phone numbers the doctor can reach you today, including the area code (list up to two):
Primary contact:*
Phone Number*

Area CodePhone Number
Type of phone (cell, home, work, other)*
Secondary Contact
Phone Number

Area CodePhone Number
Type of phone (cell, home, work, other)
Immediate access via text?

Area CodePhone Number
Any time you will be unreachable during the day?*
Procedure/Problem:*
For mass/lump removals- Please provide a description of the mass(es) and location(s):
Please confirm masses with technician at check in.
Please list any medications your pet takes on a daily basis (for pain, behavior, thyroid, etc):
Would you like your pet's nails clipped and ears cleaned/plucked (if needed) while he or she is under anesthesia at no charge? Please Select:*
Available for an additional fee with non-anesthetic procedures
Dental patients, extractions: Please select one of these options:

I authorize my pet to have dental cleaning, extractions, and minor oral surgery as neededPlease call me first but proceed with extractions or minor procedures IF AM NOT AVAILABLE
ANESTHESIA PATIENTS: BLOOD TESTING IS REQUIRED AND IF NOT DONE PRIOR TO SURGERY, TESTING WILL BE DONE TODAY.
**Please inform the technician at check in if pet has had any diarrhea or vomiting in the past 72 hours, or has had food or pre-anethestic med pack the morning of the procedure**
I, the undersigned, hereby certify that I am the owner or duly authorized agent for the owner of the aforementioned animal. I hereby give Greater Annapolis Veterinary Hospital full and complete authority to perform the medical, surgical, and/or anesthetic procedure(s) indicated as well as administering pain medications as needed. I understand there is always a slight risk involved in sedatives or anesthetics.
Printed name of owner/agent:*
Signature of owner/agent:*

Clear
Today's Date:*

MonthDayYear
Date
If you would like a copy of this form for your records, please enter your email below.
example@example.com
Should be Empty:

GREATER ANNAPOLIS VETERINARY HOSPITAL