Consent and Authorization for Avian Medical and/or Surgical Procedures
Full Name
*
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Your Pet's Name
*
Age
*
Sex
Please Select
Male - Neutered
Male - Not Neutered
Female - Spayed
Female - Not Spayed
Unknown
Weight
*
Species
*
What procedure/surgery is your pet being admitted for today?
What is the best number to reach you at during the procedure?
*
Is your bird flighted?
Yes
No
When is the last time your pet ate?
*
Have they been eating normally?
Yes
No
Did you bring their own food?
Yes
No
If not, what brand/type of food do they eat?
How does your pet normally consume water? (bowl, bottle, etc)
Did you bring your own cage?
Yes
No
Do you normally cover your cage at night?
Yes
No
Has your bird been having normal droppings
Yes
No
Specify Amount
*
Describe appearance
Has your bird had any regurgitation?
Yes
No
Does your bird lay eggs?
Yes
No
If so, when was their last clutch, and how many eggs were in it?
Please list any medications your pet is currently taking
What time was their last dose taken?
Do you need any refills? If so, please describe and include and syringe feeding formulas
Do you authorize us to do bloodwork?
Yes
No
Election of CPR vs DNR
Cardiopulmonary Resuscitation versus Do Not Resuscitate
CPR: I request that in the event of a situation where my pet begins to experience cardiac and/or pulmonary arrest, that the doctors and the staff immediately begin to perform resuscitation CPR efforts. I acknowledge that I will be responsible for any additional fees for these resuscitation attempts, which are incurred above any other estimates given.
DNR: I request that in the event of a situation where my pet begins to experience cardiac and/or pulmonary arrest, that the doctors and the staff do not attempt any resuscitation CPR efforts.
Any other questions or concerns?
Signature
*
Date
*
-
Month
-
Day
Year
Date
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