Critter Care Animal Clinic - 2024 Authorization for Mass Removal 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 MASS REMOVAL 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

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

Biopsy- Cost is $170 - I understand that without a biopsy we will not know what the mass is, if we got good margins, or if it will come back or spread to other areas of the body.

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

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

YesNo

If further procedures are necessary how should they be handled? Please choose ONE of the following options:

Perform whatever procedures are needed with the understanding there will be additional charges.Please call me at the number listed below 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 reach me 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

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Critter Care Animal Clinic - Authorization for Mass Removal Surgery

AUTHORIZATION FOR MASS REMOVAL SURGERY

If further procedures are necessary how should they be handled? Please choose ONE of the following options: