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20
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1
Date of Procedure:
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Date
Year
Month
Day
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2
Your Name
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First Name
Last Name
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3
Pets Name
*
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Patients name
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4
Brief Description of Procedure(s) to be Performed:
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5
Phone number:
*
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BEST phone number to call during your pet's procedure to approve treatments or call in case of an emergency.
Area Code
Phone Number
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6
Estimated Cost:
I have a received an estimate for all services to be performed. The dollar amount I am expecting to pay the day of my pet's procedure is:
*
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Please enter numerical amount/ range below:
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7
Food Allergies:
We love to make each visit a positive experience. We would love to reward your pet with a tasty treat while being in the clinic today. Is this okay?
*
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Yes, please!
No, thank you
No, thank you. My pet has known food allergies.
No, thank you. My pet has known GI sensitivities.
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8
Preoperative Appointment:
Have you come in for a preoperative surgical appointment or medication pick up? You will be administered medications to start the night before surgery and (if applicable) we can collect any lab samples necessary to complete prior to anesthesia.
*
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YES
NO
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9
Optional Preoperative Medications:
Our veterinarians recommend an oral preoperative antiemetic (Cerenia). This will decrease side effects caused by surgical medications such as nausea & acute vomiting. It will also help to improve recovery & help your pet return to normal feeding sooner.
*
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(Additional Charge)
Yes
I would like more info please
No
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10
Bloodwork:
We strongly recommend blood-work prior to any anesthetic procedure. Although the blood profile does not totally eliminate risk, it greatly reduces the possibility of complications from liver or kidney dysfunction. (Medically compromised or patients 5 years old - REQUIRED)
*
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I accept a Comprehensive blood screening- CHEM 17, CBC, electrolytes - (Please note: Required for patients over 5 year of age.)
I accept a Basic Blood screening - CHEM 10, CBC, electrolytes
Blood-work has been completed
I decline bloodwork at this time.
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11
Additional Services:
*
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Microchipping- permanent way to identify your pet if lost or stolen (*Additional Cost)
Electrocautery- cuts and cauterizes to minimize bleeding and improve healing and recovery (*Additional Cost and REQUIRED over the age of 1 year or if patient weighs over 50lbs)
Subdermal Local Block to reduce pain at the incision site (*Additional Cost)
Cold Laser Treatment- reduces swelling, inflammation, and accelerates healing process (*Additional Cost)
Dental prophy (scale and polish) added to primary surgery (*Additional Cost)
Decline the above services
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12
DENTAL PROCEDURES ONLY (Radiographs)
: Dental radiographs are highly suggested during oral procedures. 97% of dental disease can only be found under the gum line with radio-graphic imaging. Would you like us to perform imaging for your pet? (Grade 3 or higher & known extractions - REQUIRED)
*
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Please select "n/a" if this tab does not apply to your pets' procedure.
Full Mouth Radiographs
I decline Oral Radiographs
N/A
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13
DENTAL PROCEDURES ONLY:
If your pet has infected or painful teeth, your pet may require dental extractions. We will make every effort to contact you if your pet requires major extractions, however, in the event we cannot reach you during your pets procedure, do we have permission to extract infected, loose or painful teeth?
*
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Please select "n/a" if this tab does not apply to your pets' procedure.
I Accept extractions
I Decline extractions
N/A
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14
ABDOMINAL PROCEDURES ONLY:
There may be an additional charge of $55 or more if your pet is in estrus (in heat), overweight, or otherwise at the time of the surgical procedure. These procedures require additional precautions, time and material. This charge does not include any additional medication that may be needed at the time services are rendered.
*
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I understand and accept these terms
I Decline these terms
N/A
Other
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15
MASS REMOVAL PROCEDURES ONLY
: Pathology helps us determine/confirm the type of tumor on a patient. It also helps determine if it is metastatic or benign and also if it is likely to come back or spread. In many tumor types this is how we grade the tumor.
If you have additional questions about pathology, a member of our team would be more than happy to answer them. Please do not hesitate to call.
Accept: I accept additional testing of the tumor and understand that there will be additional charges.
Decline: I decline additional testing at this time.
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16
Vaccine Protocols:
I am aware that RABIES vaccinations are required by state law and other vaccinations are required by Mills animal hospital for the protection of my pet and other patients. I understand that my pet MUST be up to date on all required vaccinations while in the hospital. (Other required vaccines include: DHPP, Rabies, Bordetella, & FVRCP. Without proof of vaccination, your pet will be be vaccinated while in our hospital.)
*
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PLEASE INITIAL
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17
Flea Infestation Policy:
We take pride in our commitment to maintaining top quality medicine and excellent patient care here at Mills Animal Hospital. All patients dropped off for treatment or procedures are checked for fleas prior to entering our kennel. If your pet is found to have fleas, we have permission to treat your pet with a Capstar (*Additional Cost)
*
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PLEASE INITIAL BELOW:
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18
Estimate Disclosure Statement:
By signing below I certify that I have read, understand, and have had all of my questions answered to my satisfaction and I agree to the conditions of treatment listed in the estimate provided. I understand that it is only an estimate and the final bill may differ depending on the medical needs of my pet. I am encouraged to discuss all fees related to such care prior to services rendered. I am the owner, agent of the owner, or Good Samaritan responsible for seeking veterinary care for the pet identified, and certify that I am eighteen years of age or over. I do hereby give Mills Animal Hospital complete authority to perform the procedure(s) outlined in the provided estimate. I accept that my financial obligations remain regardless of the outcome. I, understand and agree that payment is due in full at time of service and I consent that my animal will not be released from the care of Mills Animal Hospital until said payment is received.
*
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Please Sign Below
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19
Surgery Consent Statement:
I have been advised as to the nature of the procedure(s) or operation(s) and the risk involved. I realize that results cannot be guaranteed. I, do hereby certify that I am the owner (or duly authorized agent for the owner) of the animal described above, that I do hereby give Mills Animal Hospital complete authority to perform the surgical and/or dental procedure. I understand that you will use all responsible precautions against injury, escape and, or death of my pet but Mills Animal Hospital will not be held liable for or responsible for this matter, as I assume all risks involved. I do hereby forever release the doctor, his agents, servants, or representatives from any and all liability arising from said surgery on said animal. I have read and understood authorization and hereby accept and agree to the terms of the consent for treatment.
*
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PLEASE SIGN BELOW:
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20
CPR:
In the event that my pet should experience cardiac or respiratory arrest while being hospitalized, do you give consent for resuscitation efforts to be initiated until you can be contacted further and notified of of your pets status? (Cost: $270+). By consenting to this service, you are also acknowledging that certain fees will apply. If you are not able to be contacted immediately, resuscitation efforts will be continued to be performed at the doctor’s discretion.
*
This field is required.
Please Note: This disclaimer is provided to all in hospital patients. While we do not anticipate complications, we would like to be prepared in the case of an emergency. *NOTE: You must accept of decline this section before submission.*
I agree to CPR being performed in case of arrest ($250-500 or More)
I elect a “Do Not Resuscitate” status
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21
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SURGERY CONSENT FORM
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