To Whom It May Concern:



PET’S NAME ________________________ BREED ______________________ ACCT#_____________

COLOR/MARKINGS ________________________ AGE ________ MALE/FEMALE ________

I, being responsible for the above described animal, have the authority to grant you my consent to receive, prescribe for, treat, and/or operate upon my pet. I understand the surgery or treatment contemplated is:

_________________________________________________________________________________________________

There are always risks associated with anesthesia and surgery. We use the safest inhalation anesthetic available and strive to provide safe anesthesia for the procedure being performed. There are many options available to lower the risks involved and increase your pet's comfort and freedom from pain. As part of our professional and ethical obligation, we are making you aware of these procedural options and providing you the opportunity to request or decline these services.

( ) Accept ( ) Decline PRE-SURGERY BLOODWORK

Although your pet will receive a pre-anesthetic physical exam, there are many medical conditions that cannot be detected by a physical examination alone.  We recommend pre-anesthetic blood testing to evaluate the kidneys and liver before we administer any anesthesia. 

Blood work helps identify health issues that could change an anesthetic protocol and/or could change the recommended course of treatment for your pet.  It also provides our veterinarians with a baseline of information if your pet should ever develop a medical problem in the future.  Blood work results will be reviewed prior to starting the procedure.  If any significant abnormalities are detected, we will contact you and discuss further diagnostics and/or recommendations.

( ) Accept ( ) Decline/NA HEARTWORM & TICK-BORNE DISEASE TESTING

Our clinic recommends heartworm prevention medication for your dog year round. In order for your dog to start or continue this medication it must be tested with a simple blood test once a year.

( ) Accept ( ) Decline/NA APPROPRIATE VACCINATIONS ( $___________)

Our clinic recommends all animals be vaccinated to prevent disease. Your pet is due for a booster of _______________.

( ) Accept ( ) Decline/NA HISTOPATHOLOGY

If your dog is having a tumor removed, it is recommended to send off the tissue to the laboratory to determine what type of tissue is present. This information can indicate the likelihood of recurrence, invasiveness of the tissue, potential for metastases, and prognosis.

The clinic is to use all reasonable precautions against injury, escape, or death of my pet, but the clinic will not be held liable or responsible in any manner in connection therewith as it is thoroughly understood that I assume all risks.

All charges including boarding costs shall be paid upon release from the clinic.

If evidence of fleas is found, your pet may be treated with a flea prevention product at your expense.

After carefully reading the above, I have signed in agreement.

________________________________________ _________________

Signature of owner or responsible party Date

Emergency Daytime Phone: ______________________ Emergency Evening Phone: ______________________

( Please text me for updates regarding the procedure at the following number ___________________________.

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