Critter Care Animal Clinic - Authorization for Surgery

Date

Email

example@example.com

Client

First NameLast Name

Address

Street Address

CityState / Province

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Phone

Please enter a valid phone number.

Pet

Species

Breed

Sex/Color

Birthday

Date

Microchip

List any current medications & last time given:

The following information is necessary in order that we might serve you better and give you more personal attention. Please fill out the form completely and double check your personal information above to be sure everything is current. Thank you.

AUTHORIZATION FOR SURGERY
I, owner or authorized agent of admitted patient, hereby authorize the admitting veterinarian (and his/her designated associates or assistants) to administer treatment as necessary to perform the following surgical, dental, or diagnostic procedure, and additional procedures as are considered therapeutically and/or diagnostically necessary. I also consent to the administration of such anesthetic
as necessary. While your pet is under anesthesia he/she may receive a complimentary ear cleaning and nail trim. Please notify an employee if these services are declined.

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

Was your pet fasted? (Did not eat for 8-12 hours minimum?)

YesNo

Home Again Microchip? (Includes one year registration) Cost is $45

YesNoPet is already microchipped

Spay Tattoo (~1 inch green line by incision; NO CHARGE - recommended if microchip isn't present)

YesNo

Dog owners - Do you wish blood to be drawn from your pet for a Heartworm Test? Cost is $60

YesNo

Cat owners - Do you wish blood to be drawn from your pet for a FeLV/FIV/HW test? Cost is $62

YesNo

Therapeutic Laser - This is performed after surgery to help reduce pain and inflammation as well as speed healing of tissue. Cost is $15

YesNo

E-Collar - Do you wish to have an e-collar (cone collar) sent home to protect the surgical site from complications that can be caused by licking/chewing? Cost depends on patients size.

YesNo, I decline and understand the riskI have one at home already

Pre-anesthetic Bloodwork - This is STRONGLY recommended for all patients and is REQUIRED for pets 10 years orolder. Bloodwork helps identify pre-existing conditions that may or may not be physically evident and may affect the drugswe can use for anesthesia. Our blood profiles include measurements of your pet's liver and kidney function, red blood cellcount, white blood cell count, platelet count, etc. Cost is $92-$130

YesNo

If further procedures are necessary how should they be handled?

Please check ONE of the following options:

Perform whatever procedures areneeded with the understanding there willbe additional charges.Please call me at the number listedbelow FIRST, but if you cannot reach me,you may proceed with an additionalprocedures with the understanding therewill be additional charges.Do nothing else unless you reachme FIRST. I understand you will wake mypet without doing the simplest procedure.

I further understand that no guarantee of successful treatment is made. I hereby certify that I have read and understand this authorization, the reasons that this procedure is considered necessary, as well as its advantages and possible complications, if any. I will not hold Critter Care Animal Clinic, the doctors, or the staff liable for any complications. I assume financial responsibility for all charges incurred to the patient and agree to pay all charges at the time the patient is discharged. I understand that if my pet is not current on his/her rabies vaccination, it will be updated at the time of service. I also understand that any patients found to have fleas will be treated at the owner's expense.

I understand that there may be risk involved in these procedures. In the event of a cardiopulmonary arrest (loss of normal heart beat and breathing), I understand immediate action must be taken. I authorize ONE of the following:

Cardiopulmonary Resuscitation (CPR) as deemed necessary by the doctor to try to restore normal heart beat & breathing.(Additional charges will apply).No resuscitation efforts

Date

Signature

Emergency Phone Number

Please enter a valid phone number.