Patient Drop-Off Consent Form For Sedation, Anesthesia, Diagnostics, and/or Treatments
Please fill out this form as completely and accurately as possible.
Owner Name
*
First Name
Last Name
Patient's Name
*
Email
*
example@example.com
Phone number at which owner can be reached today or tomorrow:
*
Please enter a valid phone number.
Additional number
Please enter a valid phone number.
Anesthetic and surgical procedure(s) to be performed:
Do you have any questions or concerns for the doctor today?
After Procedure:
A doctor or technician will contact you after your pet’s procedure. Do you prefer a text or call?
Text
Call
Do you have any time restrictions for pick up? If so, when are you available?
After your pet’s procedure is complete, would you like to have a secure link sent to your phone for payment? If so, please indicate Debit/Credit or Care Credit.
Yes - Credit/Debit card
Yes - Care Credit
No - plan to pay at pick-up
Are there any additional questions or concerns?
Is your pet on any medications
Yes
No
If yes, please list the medication name, dosage, and frequency:
Has your pet ever had any adverse reaction to any medications, vaccinations, or other procedures?
Yes
No
If yes, please provide what medication, vaccination, or other procedure, and the dates:
Do you need an e-collar?
Yes
No
In the last week, has your pet been coughing, sneezing, vomiting, diarrhea? If yes, please explain below:
If your pet is here for a Spay, have they had a heat cycle?
Yes
No
If YES, when?
If your pet is here for a Neuter, have both testicles descended?
Yes
No
Do you want a microchip implanted today?
Yes
No
When was the last time fed?
Any other concerns/allergies/procedures?
I, the undersigned owner or agent of the pet identified above, authorize the staff of Farms Veterinary Clinic to perform the above procedure(s).
*
I have read and understand
I understand that financial responsibilities for services are rendered at the time of discharge.
*
I have read and understand
I understand that some risks always exist with anesthesia and/ or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated.
*
I have read and understand
I am over 18 and 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.
*
I give my permission [yes]
I do not give my permission [no]
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, 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 have been provided an estimated cost for the procedure(s) listed above. I assume financial responsibility for the recommended services and will provide payment in full at the time my pet is discharged from the hospital. I have read and fully understand the terms and conditions set forth above.
*
I have read and understand.
I certify that I am 18 years of age or older and responsible for the financial and medical decisions for the above-mentioned pet.
*
Yes
No
Your Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Your initials in place of signature.
*
Submit
Should be Empty: