Our goal is to get your pet back to you as soon as possible, however, due to the unpredictability of surgery, some pets may not be able to leave until after 5pm. We ask that you wait until we call to let you know a pick-up time before coming to get your pet. Please also note that your pet’s procedure may not begin until later in the afternoon.

Client Name*

First Last

Spouse

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Pet Name*

Pet Information*

Species	Breed	Color	Birthdate

Sex*

Please list all medications your pet is taking and when they received them last*

When did your pet last eat, and what did they eat?*

Has your pet been ill in the last 30 days?*

Is your pet allergic to any medications?*

Yes
No

Which medications?*

What kind of heartworm/flea prevention does your pet receive?*

DENTAL TREATMENT: Please understand and be aware that a complete examination of the teeth and gums is impossible until the patient is anesthetized. The Veterinarian always performs a thorough gross examination during consultation. There is a fee for this service whether a procedure is performed or not performed/declined. We need your understanding and consent to proceed with other treatments as needed while your pet is under anesthesia. Minor extractions and other minor procedures are performed unless you specifically direct us not to do so. Major procedures require your further consent. If these procedures are necessary, your estimated charges are altered by the additional procedures. If we are unsuccessful in reaching you, necessary procedures will be performed.

Due to the need of some specific dental instruments being used and the safety of your pet, we may need to shave around your pet's muzzle area during the procedure. Do we have permission to shave if necessary? (Please check one)*

Yes
No

Phone numbers where you can be reached*

I am the owner or agent for the above described animal and have the authority to execute this consent and the authorization of the above names surgeries and/or procedures.

I understand that during the performance of the procedure(s) unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure(s)or even different procedure(s) than those set forth previously. I understand the benefit of performing needed additional procedures now and avoiding an additional anesthetic episode. I hereby consent and authorize the performance of such procedures as necessary and desirable in the exercise of the veterinarian's professional judgement. I understand the nature of the procedure(s) as well as the risks involved and also realize that results cannot be guaranteed.

I additionally authorize the use of the appropriate anesthesia, pathologist examination of the excised tissue, medication for post procedure pain management as deemed appropriate by the veterinarian, the administration of other medications, and I understand that hospital staff will be utilized as deemed appropriate or necessary by the veterinarian.

Some of the above could result in additional charges above your estimate. I have read and understood this authorization and provide my consent by signing below.

Signature*

Date*

Anesthesia Release Form

Location

Office Hours