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Anesthesia Consent FormOwner’s name: ______________________________________________ Name of Animal: _________________ Species: _______ Sex:_______Breed: ___________________ Age: __________ Color:______________Daytime Phone Number: _________________I , the undersigned, do hereby certify that I am the owner or duly authorized agent for the owner of the animal described above and have the authority to execute this consent. I hereby authorize the performance of professionally accepted anesthetic procedures necessary for its treatment. I have been advised as to the nature of the procedure and the risks involved in performing anesthesia to the above described animal. I realize that results cannot be guaranteed. Pre-op lab work is available. While it is recommended, it is not required except for animals 8 years of age or older.SPAY ______ NEUTER ______ (initial your consent) Feral Cat Ear Tip? Yes No I have read and understand this authorization and consent. I further understand that I assume financial responsibility for all services rendered.__________________________Date______________Please initial additional procedures that you want performed:*Failure to initial a procedure equals your refusal of that procedureDental ____ Tooth Extraction ____ Tumor Removal ____ Hernia Repair ____ Pre- Op Lab work ____Histopathology____VACCINES/TEST: DA2PP (5-1) ____ DA2PPL (8-1) ____ Bordetella ____ Rabies ____ FVRCP (3-1) ____ Rabies Tag ____ Microchip ____ Occult Heartworm Test ____ Feline Felv/FIV Test ______ Fecal Exam ______ Deworm ______ GROOMING: Bath ____ Groom ____ Shave down ____ Nail Trim ____ Ear Cleaning ____ Anal Gland Expression ____ Flea Prevention _______ Heartworm Prevention (requires current heartworm test) ____ ................
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