Patient Name*Age*Sex*Species*Breed*I am the owner or the authorized agent for the owner of the animal described above, and I have the authority to execute this consent. My signature below certifies that I am over eighteen years of age. I have been informed that there are certain risks and complications associated with sedation, anesthesia, and/or any operation/procedure and that the risks/complications have been explained to me. I further understand that during the course of the operations or procedures, unforeseen conditions may arise that may necessitate the performance of additional procedures deemed necessary by the veterinarian. I am encouraged to discuss any concerns I have about these risks with the attending veterinarian before the procedure is initiated. I authorize the use of appropriate anesthesia and pain relief medication as needed before, during or after the procedure. I have been informed that there are risks associated with the use of any medication. The nature of these operations or procedures has been explained to me and I understand what will be done. I am aware that the practice of veterinary medicine is not an exact science and, thus, there are no guarantees for successful treatment. I have been encouraged and given the opportunity to discuss any questions I may have regarding my pet's medical care and my questions have been answered to my satisfaction. I accept that my financial obligations remain regardless of the outcome.If your pet has fleas, a CapStar (24 hour flea control) will be administered to your pet, a $7.50 charge will be added to the invoice. In the event that (Patient’s name) should experience cardiac or respiratory arrest while being hospitalized today, do you give consent for resuscitative efforts to be initiated until you can be contacted further and notified of (Patient’s name) status? By consenting to this service, you are also acknowledging that certain fees will apply. If you are not able to be contacted immediately, resuscitation efforts will be continued to be performed at the doctor’s discretion. Please select your choice below.I agree to CPR being performed in case of arrest*YesNoI elect a “Do Not Resuscitate” status in case of arrest*YesNoAdditional Procedures OfferedPlease select the services you want performed on your pet Pre-anesthesia Blood Testing - $55.50 Nail Trim - $9.25 Anal Gland Expression - $9.25 Heartworm Test (Canines) - $38.50 Feline Leukemia/Aids Test (Felines) - $42.50 Microchip Implantation - $49.50 Nail Trim with Dremel - $44.25 Clean Ears - $12.75 Dental X-Ray (1-3 Views) - $90.00 Dental X-Ray (Full Mouth) - $150.00 Extractions - may vary I have read and understand this authorization and hereby accept and agree to the terms of the consent for treatment.Client's Name*Client's Signature*Date* Date Format: MM slash DD slash YYYY Best phone number to reach you today?*Text or Call?*TextCallCAPTCHANameThis field is for validation purposes and should be left unchanged.
