ANESTHESIA, DENTAL, & SURGICAL RELEASE

Owner's Name*

First NameLast Name

Pet's Name*

Reason for Visit*

If you chose "Other" in the last section, please explain.

Date of Procedure*

Date

Please select all that apply to your pet...*

Pet is up to date on vaccinesPet is on heart worm preventionPet has had recent vomiting, coughing, or diarrhea*Pet is allergic to any drugs/vaccines*Pet has had illness or injuries in the past month*Pet is currently on medications of supplements (e.g. vitamins, joint supplements, probiotics)*None

If you selected any item with a (*) star beside it, please explain here (include names of medications/vitamins/suppliments and when each was last given, if applicable).

Have you already received an estimate for this procedure?

YesNo (If no, please request one prior to your visit or at pet drop-off.)

Please select any of the following vaccines you would like to have given to your pet during their procedure, if appropriate. (Additional charges will apply.)*

No vaccines wantedUpdate PAST Vaccines: I would like for the medical team to update all vaccines my pet has had in the past that are now or nearly due. (NOTE: The medical team must have record of past vaccines in order to do this.)Give ALL RECOMMENDED Vaccines: I would like for the medical team to give all recommended vaccines, some of which my pet may have had in the past, based on best practice, common illness, local laws, my pet's vaccine history, etc. (I understand some vaccines may be new to my pet.)Give ONLY ESSENTIAL Vaccines: I would like for the medical team to only update or administer vaccines the medical team deems essential based on best practice, common illness, local laws, my pet's vaccine history, etc. (I understand some vaccines may be new to my pet.)Rabies VaccineDistemper/Parvo/LeptoKennel Cough VaccineOther Vaccines

If you selected "Other Vaccines" or would like to explain your choice, please specify here. (Additional charges will apply.)

If you would like any additional procedures or treatments performed during your pet's visit, please specify here. (e.g. lump removal, nail trim, ear cleaning, etc. Additional charges will apply.)

In the case that St. Francis Pet Hospital cannot make contact with me during my pet’s procedure and unexpected, NON-LIFE-THREATENING circumstances arise, I authorize the attending veterinarian to perform any services deemed necessary, even if this raises my final bill above the estimated cost of the original procedure. (Such services might include, but are not limited to, additional tooth extraction, non-routine surgical procedures, retained testicle removal, foreign body removal, bloodwork, etc.)(Select answer)*

YESNO

In the case that St. Francis Pet Hospital cannot make contact with me during my pet’s procedure (including non-contact due to urgency of emergency at hand) and unexpected, LIFE-THREATENING or emergency circumstances arise, I authorize the attending veterinarian to perform any services deemed necessary save my pet, even if this raises my final bill above the estimated cost of the original procedure. (Select answer)*

YESNO

Note: Unless otherwise requested, cats may be marked with small stomach tattoo when spayed or neutered. This is to prevent future attempts to spay or neuter the cat if it becomes lost or rehomed by the owner.

I First Name* Last Name* (owner) consent to the administration of such anesthetics as are necessary. I further understand that no guarantee of successful treatment is made. I have provided the contact phone number(s) below and understand it is my responsibility to remain available for possible contact by St. Francis Pet Hospital while my pet is being treated. I understand that answering “NO” to any of the below questions might limit the services the veterinarian can perform on my pet. I also assume financial responsibility for all charges incurred and agree to pay all such charges at the time of my pet’s release (unless another billing schedule has been agreed to prior to the procedure). I am aware that there are additional charges if my pet is pregnant, in heat, or has retained testicles. If I have declined any recommendations made by the medical team regarding my pet’s health and safety, including but not limited to bloodwork and testing, I release St. Francis Pet Hospital of all responsibility for adverse reactions or events that may occur due to my pet taking prescription medicine, going under anesthesia, or otherwise. I understand that I am completely responsible for this decision and do not hold St. Francis Pet Hospital liable for any adverse reactions. IN ALL CASES, I release St. Francis Pet Hospital of all responsibility, apart from negligence. I hereby certify that I have read and fully understand this authorization for surgical treatment. I UNDERSTAND FULL PAYMENT WILL BE DUE AT TIME OF SERVICE.

Unless otherwise instructed by the medical team, do not give your pet any food or medication after 10:00pm the night before a procedure involving anesthesia. Please notify our team at drop-off if your pet had food or medication after that time.

Drop-off is between 8:00am-8:30am.

Please list the best phone numbers to reach you during your pet’s appointment.*

Primary Phone NumberSecondary Phone Number

Signature*

Today's Date*

Date

Please verify that you are human*

St. Francis Pet Hospital

Clinic staff to complete these fields at check-in:

Anesthesia, Dental, & Surgical Release

Dental Procedure Authorization

CLIENT AUTHORIZATION