MEDICAL CARE AUTHORIZATION

The Staff at Willow Springs Veterinary Clinic is committed to doing everything possible to keep the costs of the authorized veterinary care as close to the estimate as possible. Unfortunately, the predictability of illness and injury and the level of treatment required can not always be accurately determined, especially at the time of admission. Our staff is committed to providing our clients with the most updated medical status of your pet and the costs incurred up to that point. If at any time you do not understand the information being presented from our staff please inform us immediately so we can better serve you.

I certify that I am the owner or authorized agent of the owner. I hereby authorize Willow Springs Veterinary Clinic to admit my pet, perform the procedures described in my estimate, and administer medications, anesthesia, surgical procedures, tests and or treatments that the doctors deem necessary for my pet's health, safety and well being while under their care and supervision. The preliminary diagnostic and therapeutic procedures have been explained to me along with the inherent risks and possible complications. An estimate of the costs for veterinary services has been provided to me and I have been encouraged to discuss all fees related to such care before services are rendered and during my pet's ongoing medical treatment. I understand that no guarantee or warranty has been made as to the response to treatment, and this estimate does not include charges related to complications. I agree to be responsible for ALL charges related to the care of my pet and I understand that there will be additional charges for any follow up visits or aftercare including but not limited to: recheck visits, follow-up diagnostics, and bandage changes.

I understand and consent

Authorization for Cardiopulmonary Arrest:

Should my pet require cardiopulmonary resuscitation (CPR), including cardiac compression, defibrillation, emergency drugs, or other heroic interventions, I request that the doctor(s) at this hospital pursue such medical care as indicated below. Regardless of my pet's survival, I agree to pay the fees associated with this emergency care IN ADDITION to any estimate for previously proposed care.

NO cardiopulmonary resuscitation (CPR) efforts: Only the administration of pain medication to help ease my pet's passing.Cardiopulmonary resuscitation (CPR) Efforts: to attempt to restore normal heart function and breathing as deemed necessary by the doctor until I can be reached.

I agree to be readily available via phone or in person should my pet require manual resuscitation. If I fail to do so, Willow Springs Veterinary Clinic has my authorization to use their best judgement for determining whether life-support should be continued.

I UNDERSTAND AND CONSENT

I agree to and understand the following:

To pay any additional fees if medical care exceeds the initial estimate.That changes in my pet's condition or discovery of other findings during treatment may necessitate a change in, or an extension of, the original estimate. If this occurs, a staff member will attempt to contact me to update this figure. In the event that I cannot be reached, Willow Springs Veterinary Clinic has permission to proceed with medical care for life-threatening conditions.To pay the balance of all charges IN FULL at the end of the hospitalization or completion of services. *A service charge of 1.5% per month will be added to all past due invoices. If it is necessary to bring legal action to enforce the collection of any delinquency, all collection fees, attorney fees and court costs will be included in the balance due.

Pre Anesthesia Surgery Consent

MAIN CONTACT/EMERGENCY #'S - This person must be both reachable by phone and capable/authorized to make medical and/or financial decisions for this patient.

Full Name

Contact #

Alternate contact name and number

Pet's Name

Procedure to be performed

Total # of growths to be removed

Location(s) of growth(s) to be removed (if applicable)

Are we sending out growth for biopsy? (YES to biopsy or NO to decline biopsy)

NOTE: LIKE YOU, OUR GREATEST CONCERN IS THE WELL BEING OF YOUR PET. BECAUSE OF THIS, WE REQUIRE THAT ALL PETS HAVE SCREENING TESTS PRIOR TO ADMINISTERING ANESTHESIA. RABIES VACCINE MUST BE CURRENT BEFORE THE SURGERY OR PROCEDURE. A PRE-ANESTHETIC BLOOD PROFILE IS REQUIRED WITHIN THE PAST TWO WEEKS TO HELP MINIMIZE ANESTHETIC RISKS DURING SURGERY.

Please read carefully and check box to indicate your understanding/consent

Anesthetic Risks: Willow Springs Veterinary Clinic offers the safest anesthetic and surgical procedures available for your pet, however, there is always an element of risk with any anesthetic procedure, and occasionally problems may occur during or after any medical or surgical procedure. For example, mild nausea, adverse drug reactions, prolonged recovery due to organ disease, and rarely death may occur. These risks increase with certain breeds e.g. bulldogs, boston terriers, persians, etc., systemic diseases, and high risk procedures. While Willow Springs Veterinary Clinic and their staff will strive to mitigate these risks I understand that they cannot be completely eliminated. I do hereby forever release the doctors and staff from any and all liability arising from said anesthetic complications.Microchip identification: Very few pets lost find their way home without permanent identification. We can implant a Home Again MICROCHIP and enroll your pet in the Home Again database while your pet is sedated. There is an additional charge. Please ADMINISTER a microchip to my pet today.I wish to DECLINE a microchip at this time.K-Laser Therapy: Laser therapy, or "photobiomodultion", is the use of specific wavelengths of light (red and near-infrared) to create therapeutic effects. These include improved healing time, pain reduction, increased circulation and decreased swelling. During the painless treatment, laser energy increases circulation drawing water, oxygen; and nutrients to the damaged area, which creates an optimal healing environment that reduces inflammation, swelling, muscle spasm, stiffness and pain. As the injured area returns to normal, function is restored and pain is relieved. At the circular level, during the laser therapy session, the infrared laser light interacts with tissues and metabolic activity increases within the cell, improving the transport of nutrients across the cell membrane, increasing cellular function and health. This highly recommended added benefit can be provided for your pet postoperative or post-procedure for an additional charge of $15.50. YES! Please perform a laser treatment post-procedure to offer my pet advanced pain reliefI will DECLINE advanced pain relief for my pet at this time.

IF YOU ARE SCHEDULED FOR A DENTAL PLEASE FILL OUT ADDITIONAL INFORMATION BELOW:

Additional Consent for Dental Procedures:

Unfortunately the exact extent of dental disease can be challenging to assess in an awake patient. Oral examinations under anesthesia may reveal abnormally loose teeth that fall out or should be extracted to prevent oral discomfort and ongoing infection of surrounding bone. Please select one of the following options in the event that unanticipated dental care is recommended by the doctor during your pet's dental procedure. Cost of extractions are variable depending on number and complexity of extraction recommendations from as low as $60 to as high as over $400.

I request that I be notified prior to the performance of any dental service not already agreed to in my estimate. I understand that if I cannot be reached a 10 minute grace period will be allowed, no further dental services will be performed and my pet will be recovered from anesthesia. If I wish to pursue the recommended procedures at a later date I understand there will be a need for additional anesthesia and expense at that time.I authorize all additional services, extractions, Doxirobe gel application, growth removals, radiographs, etc. as deemed medically necessary/prudent by the doctors of Willow Springs Veterinary. I understand additional costs may be accrued.

I authorize additional services (extractions, Doxirobe gel application, growth removals, radiographs, etc.) as deemed medically necessary/prudent by the doctor up to an additional cost (over my estimate) of $.

Signature

Date

Medical Care Authorization