You can always press Enter⏎ to continue
Countryside Veterinary Hospital - Authorization for Surgery
START
1
Client Name
*
This field is required.
First Name
Last Name
Previous
Next
Submit
Press
Enter
2
Pet Name
*
This field is required.
Previous
Next
Submit
Press
Enter
3
Date of Procedure
*
This field is required.
-
Date
Year
Month
Day
Previous
Next
Submit
Press
Enter
4
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
Previous
Next
Submit
Press
Enter
5
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.
All pets will be given a Capstar, which kills fleas for 24 hours, upon arrival at Countryside.
At a doctor’s discretion, a Heartworm Test may be completed at a charge of $44.99.
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.
Previous
Next
Submit
Press
Enter
6
Post Operative Pain Medication and IV Fluids are Included with every Surgical Procedure.
Previous
Next
Submit
Press
Enter
7
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 and CBC $158.96
PCV/Chem 10 $77.14 (Required for patients 8 years and older)
No, I decline the additional bloodwork
Chem 17, electrolytes and CBC $158.96
PCV/Chem 10 $77.14 (Required for patients 8 years and older)
No, I decline the additional bloodwork
Previous
Next
Submit
Press
Enter
8
I would like for the following options to be performed while my pet is here today.
*
This field is required.
Yes $22.60
No, I decline
Yes $22.60
No, I decline
E-Collar
Yes $18.23
No, I decline
Yes $18.23
No, I decline
Dremel Toenails
Yes $1.50
No, I decline
Yes $1.50
No, I decline
Alteration Tattoo
Yes $88.01
No, I decline
Yes $88.01
No, I decline
Surgical Laser
Yes $51.38
No, I decline
Yes $51.38
No, I decline
Microchip Implant
Previous
Next
Submit
Press
Enter
9
Please list all medications that the pet is currently taking.
*
This field is required.
Previous
Next
Submit
Press
Enter
10
Multiple Pets: Please initial if you would like for your pets to be kept in a cage together
*
This field is required.
Previous
Next
Submit
Press
Enter
11
Telephone number where owner/agent can be reached
*
This field is required.
Area Code
Phone Number
Previous
Next
Submit
Press
Enter
12
Email
*
This field is required.
example@example.com
Previous
Next
Submit
Press
Enter
13
Preferred method of communication
*
This field is required.
Call
Text
Email
Call
Text
Email
Previous
Next
Submit
Press
Enter
14
Pets over the age of eight are required to get a panel of blood work done.
*
This field is required.
Initial
Previous
Next
Submit
Press
Enter
15
Signature of owner/agent
*
This field is required.
Clear
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
15
See All
Go Back
Submit