Countryside Veterinary Hospital - Authorization for Surgery

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Client Name* This field is required.
First Name
Last Name
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Pet Name* This field is required.
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Date of Procedure* This field is required.
Date
Year
Month
Day
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As owner (or agent for the owner) of the pet described above, I authorize Countryside Veterinary Hospital to perform any diagnostic, therapeutic, anesthetic, emergency, and surgical procedures necessary for treating and maintaining my pet’s health and well-being. While I expect all procedures to be performed to the best of the staffs’ abilities, I realize the hospital makes no guarantee or warranty regarding the results. If my animal should injure his/ herself, escape, fail to eat, become ill, or die, I will not hold Countryside Veterinary Hospital and/or its employees responsible. I expect the hospital to use reasonable precautions to ensure my pet’s safety, and I agree to pay in full when the pet is discharged.* This field is required.
Initial
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Please check and initial each category below. I give my consent to Countryside Veterinary Hospital to perform the following procedure/care* This field is required.
If ticks are found on my pet a tick treatment will be applied for a fee of $23.50.
At a doctor’s discretion, a Heartworm Test may be completed at a charge of $40.37.
All pets being dropped off for services must be current on Rabies, Distemper/Parvo, and Bordetella. I understand that I will be liable for the charges for getting my pet up to date on any vaccination needed.
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Post Operative Pain Medication and IV Fluids are Included with every Surgical Procedure.
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Pre-anesthetic Testing* This field is required.To ensure your pet’s health and safety during surgery, we recommend bloodwork to check for liver problems, infections, and other health problems that may be missed with the physical exam.
Chem 17, Electrolytes & CBC $143.82
PCV/Chem 10 $70.94 (required for patients 8yr and older)
No, I decline the additional bloodwork
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I would like for the following options to be performed while my pet is here today.* This field is required.
Yes $16.30
No, I decline
E-Collar
Yes $12.95
No, I decline
Dremel Toenails
Yes $1.34
No, I decline
Alteration Tattoo
Yes $78.57
No, I decline
Surgical Laser
Yes $47.25
No, I decline
Microchip Implant
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Please list all medications that the pet is currently taking. * This field is required.
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Multiple Pets: Please initial if you would like for your pets to be kept in a cage together* This field is required.
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Telephone number where owner/agent can be reached* This field is required.
Area Code
Phone Number
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Email* This field is required.
example@example.com
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Preferred method of communication* This field is required.
Call
Text
Email
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Signature of owner/agent* This field is required.
Clear
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