Clone of New Patient Form

Full Name

First NameLast Name

Surgery Day Contact Telephone Number

PrimaryFormat: (000) 000-0000.

Secondary Phone Number

PrimaryFormat: (000) 000-0000.

Pet's name

Species

Authorization and Consent

I, the undersigned owner/authorized agent of the above-listed patient, hereby authorized Animal Hospital of Oshkosh and its staff to treat, hospitalize, medicate, anesthetize, or perform surgery on the said pet. I also authorize the performance of any unforeseen diagnostics, treatments, and procedures as deemed necessary for medical or surgical complications or for unexpected life-saving emergency care.

· I understand all reasonable precautions against injury, escape or death of the above-mentioned animal will be used.

· I also understand that certain inherent risks are involved in carrying out any medical procedure or handling of an animal, which is beyond the control of the person(s) involved.

· In the absence of gross negligence, I thoroughly understand that I assume certain risks and will not hold the Animal Hospital of Oshkosh, LLC, its employees, and its representatives liable or responsible in any manner or circumstances for these risks.

· The nature of the procedure(s) has been explained to me, and no guarantee has been made to the results or cure.

I authorize the following procedure(s) to be performed on the above-mentioned pet:

I have recieved and agree with treatment plan provided.

Microchip- We recommened microchipping for identification of all pets. Our Home Again Thermochip Microchip incorporates temperature biosensors with its identification technology. Although we can microchip at any time, during anesthesia is a more comfortable time for your pet. The fee includes the implantation, activation, and membership.

**For Dental Procedures Only** Extractions Dentals: After the dental cleaning our Certified Veterinary Technicians and Doctors can further examine the oral cavity. Additional dental therapies may be recommended at this time, including oral surgery (extractions). Many times, oral surgery includes x-rays, a local anesthetic, pain medication, antibiotics, extra instrumentation, and an extra inhalant anesthetic. Additional costs typically range from $200-700 depending on the surgeon's time and severity. If we cannot reach you by the phone number provided today, what would you like us to do?

Cardiopulmonary Resuscitation (CPR)In the event that your pet's heart stops, do you wish for us to perform lifesaving measures, including CPR and medications? This may incur additional costs.

Please check any of the following additional services or medications that you would like for your pet:

Signature

Date

Anesthesia Consent Form