POINT BREEZE VETERINARY CLINIC, INC. CONSENT FORM ANESTHESIA/SURGERY
Client Name:
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Address:
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Telephone Number:
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Format: (000) 000-0000.
Patient Name:
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Species:
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Dog/Canine
Cat/Feline
Are you over 18 years of age or older and able to consent to the examination of your pet?
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I am 18 years of age or older
I am not 18 years of age or older
I, the undersigned owner, or owner's agent, consent to the examination of my pet by staff veterinarians at Point Breeze Veterinary Clinic, Inc. and after consultation with me to prescribe medication for, treat, hospitalize, anesthetize, and/or perform surgery on my animal. I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with my attending veterinarian before the procedure is initiated. Should some unexpected life-saving emergency care be required, Point Breeze Veterinary Clinic, Inc. staff has my permission to provide such treatment and I agree to pay for such care.
I understand that a treatment plan of the costs for veterinary services will be provided to me, if I request it and that I am encouraged to discuss all fees attendant to care rendered and during my pet's ongoing medical treatment. If my pet is hospitalized, I agree to pay a deposit of 50% of the estimate fees and assume financial responsibility for the balance of all services on a cash, credit card, or check basis at the time my pet is discharged from the hospital. In the event my pet is hospitalized for more than 48 hours, I agree to inquire as to the medical status of my pet and the fees incurred for the medical services up to that day. In the event of an open balance, I agree to pay monthly billing and financing fee equal to 1.5% (18% per annum) of the unpaid balance.
I further agree that I, or an authorized agent of mine, will pick up my pet and pay for all accrued charges within five days after receiving written and/or oral notification that my pet is ready to be released from the hospital. Such notice will be given at the address maintained on the hospital's patient/client record or the address listed above. I agree that if I fail to comply with this policy, Point Breeze Veterinary Clinic, Inc. may handle this abandonment in the best interests of the animal and the hospital.
Should my pet experience an unexpected critical emergency including (but not limited to) cardiac or respiratory distress, Point Breeze Veterinary Clinic Inc. staff has my permission to provide such treatment and I agree to pay for such care. Please select one:
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Yes, if necessary I authorize Point Breeze Veterinary Clinic to perform emergency treatment including CPR.
No, thank you, I would like to place a DNR (Do Not Resuscitate) order on my pet.
I understand that a screening blood work panel is required for all animals undergoing an anesthetic procedure and I agree to pay for this test. (initials)
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Date of procedure:
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PROCEDURE:
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Dental cleaning with possible extractions
Mass removal(s)
Sedated X-rays
Sedated Exam
Spay (female pet sterilization)
Neuter (male pet sterilization)
Wound/laceration repair
Cystotomy
Sedated Nail trim/grooming
Specialty surgery with Dr. Chisnell (MOVES)
Signature:
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Daytime Phone:
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Format: (000) 000-0000.
If the person above is NOT the person to contact regarding discharge, please list their name and phone number. Name:
Daytime Phone:
Format: (000) 000-0000.
Please list ALL medications your pet is currently taking, including over the counter (i.e. Aspirin):
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Would you like for us to check anything else while your pet is anesthetized? (Ears, nail trim, anal glands, etc.)
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For dogs only: Are we allowed to walk your dogs outside? If so, does he/she have a "potty password" (go on command)?
As part of today's visit, I am being provided with a complimentary consultation with Pets After Dark to address any post-anesthesia questions or concerns after hours. This is valid until midnight the day following the procedure.
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Yes, Point Breeze Vet has permission to share my contact information (name, phone number, email address, pet's name, and associated medical record) with Pets After Dark.
No, Point Breeze Vet does not have permission to share my contact information. I do not wish to participate in this complimentary service.
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