Client: First Name * Last Name * Emergency Contact: First Name Last Name Phone: Area CodePhone Number
Authorized person to pick up Patient:Name: First Name Last Name Phone: # .
Dr. Luper and staff of Fur & Feather Veterinary Hospital appreciate your decision to use us as your animal health provider. Your trust in us is not taken lightly. Our goal is to always provide excellent up-to-date veterinary medicine and surgery and to treat your pet as we would our own. Because of this concern, we feel it is important to have your written consent before performing any procedure. The following is a copy of the American Veterinary Medical Association Standard Consent Form:
By filling out this form I certify that I am the owner, or agent for the owner, of the above described animal and have the authority to execute this consent.
Initials*I understand that during the performance of the foregoing procedure(s) or operation(s), unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure(s) or operation(s) or different procedure(s) or operation(s) set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) and operation(s) as are necessary and desirable in the exercise of the veterinarian's professional judgment.
Initials* I also authorize the use of appropriate anesthetics, and other medications, and I understand that hospital support personnel will be employed as deemed necessary by the veterinarian.
Initials* I have been advised as to the nature of the procedures or operations and the risks involved. I realize that results cannot be guaranteed. I do not hold Fur & Feather Veterinary liable for any illness my pet may develop that would have been prevented through recommended vaccination, laboratory testing, or other procedures.
Initials* I agree to pay for all fees incurred upon completion, and understand that no billing is available.
Initials* I understand that a complete examination of the oral cavity is impossible on an awake animal. As a result, evidence of oral disease (examples include retained deciduous teeth, teeth in need of extraction, tumors, growths, gingival disease or overgrowth) may not detected until an oral exam and dental radiographs are completed while my pet is anesthetized.
Initials* I understand that the doctor will call the above listed emergency contact information if any unexpected problems are discovered during an anesthetic procedure. IN THE EVENT THAT I CANNOT BE REACHED, I understand that the doctor will proceed with the optimal treatment including but not limited to extractions, mass removal, or oral surgery. I am aware that there will be additional charges associated with additional care and I agree to assume financial responsibility for any additional charges.
Initials* I understand that if my pet is found to have FLEAS/TICKS OR PARASITES, then appropriate treatment (DEWORMING / ORAL or TOPICAL MEDICATION) will be administered AT MY EXPENSE.
Initials* I am the owner or agent for the owner of the above described animal and have the authority to execute this consent.
Initials* I hereby consent and authorize the performance of the procedure(s) / operation(s) as in the medical care plan.
If yes, what medication, and what dosage:Medication: blanks Dosage: blank .
Medication: blanks Dosage: blank .
Additional dental products to continue home care at home:
While my pet is here for a Dental, if an illness or emergency situation occurs:
Initials* I understand that if my pet is to have FLEAS/TICKS OR PARASITES appropriate treatment (Capstar pill/topical flea prevention and/or deworming) will be done AT MY EXPENSE.
Initials* I ATTEST THAT THE PATIENT'S FOOD WAS TO BE REMOVED BY 10PM LAST NIGHT PRIOR TO SURGERY, AND TO MY KNOWLEDGE, HAS NOT EATEN ANYTHING PRIOR TO SURGERY TODAY.
IN THE EVENT THE CLIENT HAS NOT FOLLOWED POST OPERATIVE CARE INSTRUCTIONS PROPERLY, no discounted or free services will be provided to care for the complication.
I HAVE READ AND UNDERSTAND THIS AUTHORIZATION AND CONSENT
Thank you for allowing us to care for your pets!