AAH Anesthesia/Dental Consent

Aardvark Animal Hospital Anesthesia/Dental Consent
OWNERS NAME*
PETS NAME*
SPECIES*
AGE*
Anesthesia/Dental procedure to be performed:*
Date of Admission/ Surgery*

MonthDayYear
Date
Pet Information

Please answer the questions below regarding your pet.
Does your pet have any food or medication allergies?*

YESNO
If yes, please explain.
Does your pet eat raw, partially raw, or freeze dried food or treats?*

YESNO
If yes, please explain.
Is your pet on any herbal, or over the counter supplements, probiotics, or vitamins?*

YESNO
If yes, please explain.*
When did your pet last eat or drink? *
What time? *
Are you able to give your pet medications in pill form?*

YesNo
If available, would you prefer liquid to go home medications?*

YesNo
Owner Information

Our hospital will contact you prior to surgery and when your pet recovers from anesthesia. Please be sure you are available for these important phone calls.
Today's contact person*

First NameLast Name
Phone contact (1)*

Area CodePhone Number
Today's secondary contact

First NameLast Name
Phone contact (2)

Area CodePhone Number
I authorize the use of Pet Desk to contact me with updates and/or questions.*

YesNo
Authorization and Consent
I give my permission for medically necessary extractions.*

YESNOContact me for authorization.
I, the undersigned owner or agent of the pet identified above, authorize the staff of Aardvark Animal Hospital LLC to perform the above procedure.I am the owner of the animal, or have permission to act on behalf of the owner, and I am over 18 years of age.I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated.A complete physical exam will be performed on your pet prior to the surgical procedure if it has been longer than 30 days since the last exam. However, this may not identify all systemic or metabolic problems. For this reason, your pet will have a pre-anesthetic blood panel to evaluate major organ functions prior to anesthesia.While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved.I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow up radiographs, re-check physical exams, associated treatment, additional medications, and additional surgery due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions.I am aware that the treatment plan provided is an estimation only for procedures on this given day. I acknowledge the scope of the treatment plan and estimate, and I understand that actual charges may differ depending on my pet's medical needs and response to treatment. Aardvark Animal Hospital LLC agrees to make every reasonable effort to stay within the fees set forth in my treatment plan and to contact me should additional charges be deemed necessary. I agree to pay in full at the time my pet is discharged and, in the case of nonpayment, a reasonable fee per month will be charged. All collection and attorney fees necessary to collect this debt will be born to me.I understand that the attending veterinarian will make every effort to contact me regarding treatment in the case of unforeseen emergencies. If unable to contact me, the staff may or may not have my permission to proceed with life sustaining procedures.YesNo
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Signed Date

MonthDayYear
Date
Pet Owner Signature

Clear
Should be Empty:

Aardvark Animal Hospital Anesthesia/Dental Consent

Pet Information

Owner Information

Authorization and Consent