Client & Patient Details
Primary Owner Name
(Required)
First
Last
Primary Phone Number
(Required)
Secondary Owner Name
First
Last
Secondary Phone Number
Emergency Contact Phone
(Required)
Mailing Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Pet Name
(Required)
Species
(Required)
Select One
Dog
Cat
Other
Other
(Required)
Breed
Age
Gender/Status
Intact Male
Castrated Male
Intact Female
Spayed Female
Insurance Info
Informational Disclosures
Admittance, Communication Expectations, and Time Restrictions
Common and Major Risks of Sedation and Anesthesia
Authorizations & Conditionals
Has your pet ever had a complication during or after sedation or anesthesia?
(Required)
Yes
No
If yes, please describe what happened.
(Required)
Initials: Planned Sedation Authorization
(Required)
Unplanned / Contingency Sedation Authorization
(Required)
Contact me first before sedating.
Proceed with sedation if needed (Auto-notice: We will attempt contact if cost exceeds $100).
Initials: Unplanned / Contingency Sedation Authorization
(Required)
Initials: Liability Release
(Required)
Initials: Late Pickup / Boarding Policy Acknowledgment
(Required)
Signature
Date