I certify that I am the legal owner of this pet and have full authority to provide all necessary information and make any decisions on behalf of my pet.
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Initial
Pet's Name
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First Name
Last Name
Your Name
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First Name
Last Name
Best phone number to reach you on procedure day
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-
Area Code
Phone Number
Alternative Contact Phone
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Area Code
Phone Number
Date of sedation/procedure
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When was the last time your pet ate? How much did your pet eat?
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Has your pet ever experienced any adverse reactions during or after a sedated procedure in the past?
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Yes
No
Unsure
If yes, please describe/provide more information
Please list any medications, supplements, topical treatments your pet has received in the past 72 hours and when they were last given: If none have been given please state none.
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Is Your Pet Current On Vaccinations - Proof of Vaccines will be required?
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Yes
No
I Am Not Sure
Does Your Pet Have A Microchip?
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Yes
No
No, microchip while sedated
Does Your Pet Have Known Health Concerns and/or Chronic Disease or Conditions?
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If yes, please tell us more. If no, please note N/A
Is There Anything Else We Should Know About Your Pet?
If yes, please tell us more. If no, please note N/A
I acknowledge that my pet will be sedated for the following medical procedure. Please be specific and detailed about the procedure, including body part involved (e.g., head/neck/ear/leg/paw/front/back/left/right). If you are unsure, contact our office for clarification before completing this form. This information is crucial for ensuring clear communication and mutual understanding between both parties.
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While my pet is sedated, I request the following add-ons to be performed. These will be added to your final invoice:
i.e: nail trim, anal glands, ear cleaning
If your pet becomes nauseous, do you give CHEW permission to give an anti-nausea medication (cerenia) siren
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Please Select
Yes
No - I acknowledge the potential risks associated with declining this medication, including but not limited to: aspiration, reduced appetite and vomiting.
I hereby authorize the sedation of my pet at CHEW Animal Clinic today and confirm that I understand the nature and details of the procedure.
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In the event of an unforeseen emergency, we will make every effort to contact you promptly. Please be assured that we take all necessary precautions to ensure your pet is safe and in good health before proceeding with their scheduled procedure. Any known risks will be thoroughly discussed with you in advance. However, on rare occasions, emergencies can occur, and we ask that you indicate your preference in the event that we are unable to reach you. Please select your preference below:
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Please proceed with basic cardiopulmonary resuscitation (CPR). I accept responsibility for all costs incurred (starting at $175).
Please do not proceed with basic cardiopulmonary resuscitation (CPR). I accept responsibility for all costs incurred.
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Submit
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