Pet Name Breed Pet Birthday
Date Format: MM slash DD slash YYYY
List any known allergies this pet has Phone Alternate Phone Current medications and time of last dose Procedure/Surgery to be performed today Has this veterinarian previously examined this pet? No Yes I fully understand the procedure my pet is here for today No Yes Were you given an estimate of the costs for today's surgery/procedure? No Yes Would you like an estimate now? No Yes Has this pet eaten today? No Yes Vaccines Charges for vaccines are: $28.00 per vaccine, plus examination fee. Except feline leukemia vaccines which are $31.50 and influenza which are $42.50.
It is our clinic policy to require up-to-date vaccinations on all pets entering our hospital for surgery, grooming and day boarding.
Required vaccines are:
• Distemper (DALPP)
• Bordetella (ITT)
• Distemper (FVRCPC)
• Rabies I.V. (Intravenous) Fluid Therapy An intravenous catheter (I.V) is an important safety measure for anesthesia. In the unlikely event that there is a problem under anesthesia, the IV catheter allows for rapid delivery of potentially life-saving medications. Also, intravenous fluids are often given while the pet is under anesthesia to promote good hydration and help avoid a dangerous drop in blood pressure. An IV catheter and IV fluid therapy are required for some procedures such as: dental cleaning, spaying/neutering of older pets and major surgeries. The cost is included in the estimate. For safety reasons, an IV catheter (with or without IV fluid therapy) is always recommended and can be done fo procedures that do not require it. The procedure today requires an IV catheter and IV fluid therapy (cost included in estimate) I have elected to use an IV catheter during today's procedure (additional $51.85) I have elected to use an IV catheter and IV fluid therapy during today's procedure (additional $74.63) I have declined to use an IV catheter and IV fluid therapy in today's procedure Pain Control After Surgery Pain control during and after surgery is an important aspect of the healing process while also providing comfort to your pet. Pain medications will be prescribed to your pet based on the discretion of your veterinarian. Post-surgery injections and take-home medications are based on weight of pet. Cost is included with the estimate you were given. Pre-Anesthetic Blood Testing Like you, our greatest concern is the well being of your pet. Before anesthetizing your pet, the veterinarian will perform a full physical examination as well as draw a blood sample for screening. Many conditions, including disorders of the liver, kidneys or blood, are not detected unless blood testing is performed. Such tests are especially important before any kind of surgery. We require that all pets have pre-anesthetic screening. Consent I agree to the above stated. Secondary Services Offered to Surgical Patients Your pet has been admitted to the Animal Clinic today for the procedure listed on the front of this Consent Form. Many times, owners will request that other services be addressed while their pet is in our care. If you would like the veterinarian and staff to provide additional services to your pet, please indicate from the list provided. Additional Services
Select all you would like performed on your pet
Other Payment for Services Payment is due in full at the time of service. You will be expected to pay your entire bill just prior to your pet is discharged from the Animal Clinic unless you and your veterinarian at the Animal Clinic, Inc. have made other arrangements. We accept credit card and debit card payments. Owner's Release Consent The doctors and staff of the Animal Clinic, Inc. are to use all reasonable precautions against injury, escape or death of my pet. I understand that anesthesia involves risk to my pet which can be as severe as death. I also understand that surgical results cannot be guaranteed. I will not hold the Doctors or staff of the Animal Clinic, Inc. liable for an adverse outcome.