Countryside Veterinary Hospital - Authorization for Surgery

1
Client Name* This field is required.
First Name
Last Name
2
Pet Name* This field is required.
3
Date of Procedure* This field is required.
Date
Year
Month
Day
4
As owner (or agent for the owner) of the pet described above, I authorize Countryside Veterinary Hospital to perform any diagnostic, therapeutic, anesthetic, emergency, and surgical procedures necessary for treating and maintaining my pet’s health and well-being. While I expect all procedures to be performed to the best of the staffs’ abilities, I realize the hospital makes no guarantee or warranty regarding the results. If my animal should injure his/ herself, escape, fail to eat, become ill, or die, I will not hold Countryside Veterinary Hospital and/or its employees responsible. I expect the hospital to use reasonable precautions to ensure my pet’s safety, and I agree to pay in full when the pet is discharged. Initial *
5
Please check and initial each category below. I give my consent to Countryside Veterinary Hospital to perform the following procedure/care* This field is required.
All pets will be given a Capstar, which kills fleas for 24 hours, upon arrival at Countryside.
At a doctor’s discretion, a Heartworm Test may be completed at a charge of $46.99.
All pets being dropped off for services must be current on Rabies, Distemper/Parvo, and Bordetella. I understand that I will be liable for the charges for getting my pet up to date on any vaccination needed.
6
Please check and initial each category below. I give my consent to Countryside Veterinary Hospital to perform the following procedure/care* This field is required.
All pets will be given a Capstar, which kills fleas for 24 hours, upon arrival at Countryside.
At a doctor’s discretion, a Heartworm Test may be completed at a charge of $48.99.
All pets being dropped off for services must be current on Rabies, Distemper/Parvo, and Bordetella. I understand that I will be liable for the charges for getting my pet up to date on any vaccination needed.
7
Post Operative Pain Medication and IV Fluids are Included with every Surgical Procedure.
8
Pre-anesthetic Testing* This field is required.To ensure your pet’s health and safety during surgery, we recommend bloodwork to check for liver problems, infections, and other health problems that may be missed with the physical exam.
Chem 17, electrolytes and CBC $161.96
PCV/Chem 10 $81.14 (Required for patients 8 years and older)
No, I decline the additional bloodwork
All pets age 8 and older are required to have a PCV/Chem 10 at a minimum. A Chem 17, Electrolytes and CBC provides more in depth health information compared to a PCV/Chem 10.
9
I would like for the following options to be performed while my pet is here today.* This field is required.
Please Select
Please Select
Yes $24.03
No, I decline
Cone Collar to protect incision
Please Select
Please Select
Yes $19.64
No, I decline
Dremel Toenails
Please Select
Please Select
Yes $3.69
No, I decline
Alteration Tattoo
Please Select
Please Select
Yes $94.82
No, I decline
Surgical Laser
Please Select
Please Select
Yes $55.35
No, I decline
Microchip Implant
10
Please list all medications that the pet is currently taking. * This field is required.
11
Multiple Pets: Please initial if you would like for your pets to be kept in a cage together* This field is required.
12
Telephone number where owner/agent can be reached* This field is required.
Area Code
Phone Number
13
Email* This field is required.
example@example.com
14
Preferred method of communication* This field is required.
Call
Text
Email
15
Pets over the age of eight are required to get a panel of blood work done.* This field is required.
Initial
16
Signature of owner/agent* This field is required.
Clear
Should be Empty: