The following information is necessary in order that we might serve you better and give you more personal attention:Name First Last Address City Zip Phone Daytime phone Animal Species Breed Age Sex Number Weight I am the owner for the above animal and have the authority to execute this consent. I hereby authorize the following procedure(s) or operations(s): The nature of such service has been described to me to my satisfaction and I realize that no guarantee or warranty can ethically or professionally be made regarding the results or cure. I understand that anesthesia carries some risk (even though it may be small). Therefore, blood testing is recommended before general anesthesia. The anesthetic agent is removed from the body by the liver and kidneys, so it is important to know before anesthesia that these organs are functioning at 100%. Blood work helps us make this determination and is required in all pets 8 years or older. We also require fluids during surgery to help maintain blood pressure and flush out the anesthetic and ECG monitoring in our older pets. I accept / decline the Pre-Anesthesia- CBC Blood Work ($60.38) I accept / decline IV fluids during surgery($52.34) I accept / decline ECG monitoring during surgery ($38.88) I authorize/decline additional pain medication to be given if deemed necessary by the veterinarian. I accept / decline Histopathology on the growth to be removed today ($134.27) Additional ServicesWhile under anesthesia, it is an opportune time to perform other procedures. I authorize the procedures selected below for animal. Animal Please initial if you would Nail Trim($13.82) Anal Sac Expression($20.39) Microchip placement($47.51) Update Annual Exam and Vaccinations Da2P Bordetella Leptospirosis Rabies FVRCP FeLV Heartworm Test Intestinal Parasite Exam Dental Cleaning(I have read the Dental form & am aware that teeth may need to be removed) Remove Growth Location of growth Specify IF FLEAS ARE SEEN ON YOUR PET THEY WILL BE GIVEN A FLEA PREVTIONS (select one) Capstar(24 hour prevention $ 6.89 - $6.99) Simparica (30 day Prevention $ 17.12 - $18.30) I understand that I assume financial responsibility for all services rendered, and that payment is due on the date of the surgery. Any medication and supplies purchased will be at additional charge.If anyone other than yourself is picking your pet up, please list here : Signature of Owner or AgentDate MM slash DD slash YYYY
