Animal Health Care Center - Surgery Admission Form

Authorization/ Admission for Anesthetic Procedures and Surgery

Clients Name

First Last

Pets Name

Anesthetic and medical or surgical procedure(s) to be performed

The most serious complications of anesthesia/surgery include: Respiratory arrest and/or cardiac arrest.

Is your pet allergic to any drugs?

Yes

Has your pet had any illness or injury in the past 30 days?

Yes

Any history of seizures and/or previous anesthetic problems?

Yes

Current medications our medical staff are not aware of?

Yes

If yes, please list what they are

I, the undersigned owner or agent of the owner of the pet identified above, certify that I am

Age Confirmation(Required)

I am eighteen years of age or over

I am not eighteen years of age or over

and authorize the veterinarian(s) at this practice to perform the above procedure(s). 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. My signature on this form indicates that any questions I have regarding the following issues have been answered to my satisfaction:

The reasonable medical and/or surgical treatment options for my pet
Sufficient details of the procedures to understand what will be performed
How fully my pet will recover and how long it will take
The most common and serious complications
The length and type of follow-up care and home restraint required
The estimate of the fees for all services
Any necessary payment arrangements

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that veterinary medicine is not an exact science and that no guarantee or warranty has been made regarding the results that may be achieved. I agree to pay a deposit of 100% of the estimated fees, assume financial responsibility for the remaining fees, and provide payment via cash or credit card at the time my pet is discharged from the hospital. Should unexpected life-saving emergency care be required and the hospital staff is unable to reach me, the staff

Emergency Care Permission(Required)

Has my permission to provide such treatment

Does not have my permission to provide such treatment

and I agree to pay for such services.

In the event my pet is hospitalized beyond the first day at this facility, I understand that veterinary care during nighttime hours and/or weekends is provided at the discretion of the attending veterinarian. Continuous presence of personnel may not be provided during these hours. If I desire that my pet have supervision when this facility is closed and staff is not present, I elect to

Overnight Care Election(Required)

A) Pick up my pet and provide such care in my home, in which case I accept all risks of adverse effects

B) Have my pet stay overnight with veterinary supervision limited but still available via live stream camera system

I understand once my pet is taken home, I am solely responsible for the outcome of the recovery process, medications being administered to my pet, and providing care as directed by the veterinarian. I accept that veterinary medicine is an inexact science and that no guarantee of successful treatment has been made. I have read and understand the nature of the above procedures and give my consent to proceed. I also authorize the use of appropriate anesthetics and other medication, and I understand that hospital support personnel will be employed as deemed necessary by the veterinarian. I understand that the staff of Animal Health Care Center (AHCC) will try their best to contact me at the numbers I have provided today if there is a problem or complication during the surgical procedure. If the staff of (AHCC) is unable to reach me at the numbers I have listed today, I authorize any additional medical procedures and/or medications to be given/performed during surgery which are considered necessary by the veterinarian.

*FOR DENTALS: If the doctor determines that tooth extraction(s) is necessary,

Dental Extraction Authorization

I do authorize the performance of this procedure without prior notification

I do not authorize the performance of this procedure without prior notification

(NOTE: teeth will be extracted ONLY if the doctor deems it absolutely necessary)

Phone number for medical staff to contact owner/ guardian:

Signature of Owner or Authorized Agent

Date