Owner’s Name:
(Required)
Number you can be reached at today:
(Required)
Alternate number if someone else is responsible for post-op pick-up/care:
(Required)
Relationship to alternate:
Procedure(s) to be performed today:
We will call you if we find anything not addressed in the signed estimate. However, if you cannot be reached:
Please continue with doctor’s recommendations of the highest quality standard for my pet’s health.
Do not continue with any unexpected changes unless I can be reached. I understand that my pet may be recovered from anesthesia without recommended treatment(s) if I cannot be reached when needed.
Pre-operative Pet Questionaire:
Pet’s Name:
When is the last time your pet ate?
Has your pet had any vomiting or diarrhea lately?
Yes
No
Is your pet on any medication?
Yes
No
If yes, which medications, how often and what dosage?
Have we reviewed your pet’s pre-operative blood work results?
Yes
No
Has your pet been under anesthesia before?
Yes
No
If yes, were there any complications you are aware of?
I approve of the recommended post-operative care items if needed:
Pain medication
E-Collar / Lick Sleeve
Providing confined space for my pet to fully recover safely
Reviewing post-anesthesia expectations & post-operative in-home instructions provided by doctor
AUTHORIZATION
(Required)
I have read and accept all the information below.
I verify I am the owner (or Authorized agent for the owner) of the above named pet and authorize the above procedure to be performed. I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure(s) as directed by the veterinarian.
I have been advised of the nature of this procedure to be performed and the risks involved. I understand also that there is always a risk associated with any anesthesia episode, even in apparently healthy animals and have discussed my concerns with the veterinarian. I understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated for the safety or care of my pet. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian’s professional judgement.
I also accept responsibility for any additional charges accrued related to the additional needs of my pet.
I understand full payment is due at the time my pet is released from the hospital. I also understand I have full responsibility for my pet’s safety once released from the hospital and agree read any post-anesthesia instructions provided by Passion Fur Paws.
In the rare event a patient experiences cardiac arrest, I (...) like the team to perform CPR on my pet.
(Required)
Would
Would not
Signature of Owner:
Reset to re-sign.
Date
MM slash DD slash YYYY
Signature of Witness:
Reset to re-sign.
Date
MM slash DD slash YYYY
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