AUTHORIZATION FOR ANESTHESIA AND/OR SURGERY

Client Name:

First NameLast Name

Phone Number:

Email:

example@example.com

Does your phone number have texting ability?

Patient Name:

Breed:

Planned Procedure(s) Description:

Ex: Mass Removal, Spay, Neuter, Gastropexy, Foreign Body Removal, etc

(FOR THE NEXT SIX QUESTIONS)

Have you talked with your pet’s doctor about....

- The reasonable medical and/or surgical treatment options for your pet?

- Sufficient details of the procedure to understand what will be performed?

- How fully your 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?

Please tell us if your pet ate or drink in the morning of it's procedure:

(Fill in the blank) I _____________ over 18 years of age:

I, the undersigned owner or agent of the pet identified above, over the age of 18, and authorize the veterinarians at Waverly Animal Hospital to perform the above procedure(s). 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 doctor before the procedure(s) is/are initiated. Initial:

DISCLOSURES:

I agree that I am the owner, or agent, of the pet identified above, over the age of 18, and authorize the veterinarians at Waverly Animal Hospital to perform the above procedure(s).

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 doctor before the procedure(s) is/are initiated. These may include, but not be limited to: the reasonable medical and/or surgical treatment options available, sufficient details of the procedure to understand what will be performed, how fully your 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, and the estimate of the fees for all services.

While I accept that all procedures are performed to the best of the ability of the staff at this facility, I certify that no guarantee or warranty has been made regarding the results that may be achieved.

I agree to pay a deposit of 50% of the estimated fees, or $200, whichever the doctor requests prior to drop-off and assume financial responsibility for the remaining fees, agreeing to provide payment via cash, credit card, or check at the time my pet is discharged.

Initial that you agree to the above four disclosures:

I agree to pay a deposit of 50% of the estimated fees at drop-off and assume financial responsibility for the remaining fees, agreeing to provide payment via cash, credit card, or check at the time my pet is discharged. Initial:

Should unexpected life saving emergency care be required the staff has/does not have my permission to provide such treatment and I agree to pay for such service.

Initial:

Would you like any Pre-Anesthetic Blood Testing? Note: it is REQUIRED for pets over the age of 7, and RECOMMENDED for all over 1 year. (This was included in your estimate)

Pre-Anesthetic Blood Testing is REQUIRED for all pets. (This was included in your estimate)

Would you like a microchip inserted? If yes, complete the address portion below.

Address for microchip registration, or to update to client file:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

If yes, please list an email address for the Microchip Registration: blanks

Are any preventative services due now (or soon) that you would like performed? Rabies/Distemper/Leptospirosis/Bordetella/Lyme/Influenza/Leukemia vaccines, Intestinal Parasite Screen for stool, Heartworm test for dogs, or Leukemia/FIV test for cats). We require: RV, DHLPP, Bord., heartworm test (if over 7 months old) & stool sample for dogs and RCP, Rabies & stool sample for cats. (NOTE: Any required items will be performed, at owners expense, unless proof of service is provided at drop off)

If yes, please list what you would like performed:

Rabies (RV), Canine Distemper (DHPP), Leptospirosis (Lepto), Bordetella (INB), Lyme, Canine Influenza, Heartworm Test (4DX), Intestinal Parasite Screen/Fecal (FA), Feline Distemper (RCP), Feline Leukemia/FIV Test (FELV/FIV), Feline Leukemia vaccine (FeLeuk)

Please list any medications your pet is on (drug name, strength, directions, date and time last given):

Note: please write in continuous sentences, do not hit enter when changing medications.

Do you need any refills of medication or food?

You will be asked the name and quantity requested.

In the event my pet is hospitalized beyond the first day at this facility, I understand that veterinary care during nighttime hours and/or weekends is provided at the discretion of the attending veterinarian. Continuous presence of personnel may not be provided during these hours. If I desire that my pet have supervision when this facility is closed, I elect to:

I accept that veterinary medicine is an inexact science and that no guarantee of successful treatment has been made. I have read and understand the nature of the above procedures and give my consent to proceed.

Signed,

Please verify that you are human