Anesthesia/Surgery Consent

Name:*

Patient Name:*

**One form per pet**

Check In Date:*

Check Out Date:*

**Saturday ONLY**

Check in/Check out need to be dropped off/picked up 8-11:30am

Estimated time for Check in

Morning (9-12pm)Evening (2-5:30pm)Unknown

Estimated time for Check Out

Morning (9-12pm)Evening (2-5:30pm)Unknown

**All animals must be up to date on all vaccinations. We require vaccines for the safety of your pets, other pets, and to protect our facility from any infection.**

If fleas are found upon entering the hospital, an inexpensive pill will be given to kill the fleas.

Canine:

Rabies
DAPP/DAPPL
Bordetella (Kennel cough) required every 6 months
Canine Flu H3N8 & H3N2 (CIV)

Feline:

Rabies
RCCP (Feline distemper)

Will your pet need vaccines/additional services while in our care?*

YesNo

Is someone other than you picking your pet up?*

YesNo

Please list the name and phone number of that person*

I hereby certify that I am the owner of the above-named animal or am responsible for it and have the authority to execute this consent. I also authorize the use of such anesthetics as you deem advisable and performance of such surgical or therapeutic procedures as you determine to be indicated.

Our facility does not employ on-site personnel during the hours of 6pm-8am. Weekends and Holidays also do not have onsite personnel other than during regular walks and feeding times throughout the day. All animals boarded at the Facility will be left unattended during those times.

I also agree to indemnify and hold ANGEL ANIMAL HOSPITAL harmless from and against any and all liability arising out of the performance of any of the procedures referred to above.

I hereby authorize the performance of the following procedure(s):

Boarding: {checkIn} - {checkOut}

{input60}

Signature:*

Primary Phone Number:*

Please enter a valid phone number.

Secondary Phone Number:

Please enter a valid phone number.