Any known allergies to drugs? List of allergies:
Comments/Concerns Items left with patient
I have been advised as to the nature of the procedure/surgery and the risks involved. I realize results cannot be guaranteed. Advances in anesthesia and surgery have made routine procedures relatively safe with few complications. Nevertheless, problems can arise due to pre-existing conditions not evident during routine pre-surgical and dental exams. To minimize these possible problems, Caring Hands highly recommends pre-anesthetic blood work for all surgical and dental procedures requiring anesthesia.
I understand during performance of the procedure/surgery, unforeseen conditions may be revealed that necessitate an extension of the procedure/surgery or a procedure different than set forth. The hospital will make every effort to consult with me prior to any necessary change. Therefore, I consent to and authorize the performance of such procedures/surgeries as necessary and desirable in the exercise of the veterinarian’s professional judgment, and agree to pay for such care.
If it is deemed necessary for my pet to be hospitalized overnight, I understand that I have the option of taking my pet to a 24-hour facility, or keeping my pet at Caring Hands Animal Hospital where there is no overnight supervision.
Should unexpected life-saving emergency care be required and the attending veterinarian is unable to contact me:
I consent to and authorize resuscitation of my pet: including, but not limited to, CPR, fluids, and the administration of life-saving drugs.
I decline resuscitation of my pet: do not perform any resuscitative measures on my pet.
Canine patients are walked outside using a double-leash system every 4-6 hours.
I consent to having my pet walked outside.
I decline having my pet walked outside.
I agree to be responsible for payment in full of all charges incurred for procedures, treatments, and testing performed on my pet, including treatment for fleas or any other parasites that are present and acknowledge that payment is due at the time the patient is discharged. I further agree in the case of non-payment, I agree to be responsible for the $35 collection fee, as well as a 1.5% service fee that will be added to the account in addition to the entire amount due.
Signature of owner Date
Name and number for contact: ,