Client Full Name*

First Last

Pet Name*

Breed*

Species*

Procedure*

Ovariohysterectomy
Neuter
Dental

Would you like us to place a microchip today?*

Yes
No

Special Instructions given for today: Did your pet eat this morning?*

Yes
No

When did your pet last eat? How much and at what time?*

List any Pre-visit Pharmaceuticals given, how much and at what time?*

On any additional medication(s)? (Not including Heartworm and flea & tick preventative)*

Yes
No

If yes, name of medication(s), current dosage, quantity and when last given:*

Emergency Number*

Car Make, Model and Color*

I certify I am the owner (or agent for the owner) of the described animal(s) and have the authority to execute this consent. I hereby consent to and authorize the performance of the above operation(s) or procedure(s), and/or other procedure(s) or operation(s) that are deemed necessary and desirable in the exercise of the veterinarian's professional judgment, including use of appropriate anesthetics, and agree to pay any and all additional charges incurred. For example, during spay and neutering services, there is an additional charge if a female is pregnant or the pet is obese. In addition, if the animal is found to have fleas or other external parasites, it will be treated with a long-acting flea/tick treatment at an additional charge ($28). I understand you will use reasonable precautions to assure the animal's safety while it is in your care, but will not hold you responsible if the animal should injure itself, escape, fail to eat, become ill or expire. I absolve you of all liability arising from the performance of procedures requested herein. I understand this hospital is not staffed continuously during weeknights (approximately 6:00 p.m. - 7:30 a.m.), weekends or holidays, unless necessary due to emergency care. Patients are monitored periodically and exercised routinely as needed throughout this period. I understand payment is due, in full, when the animal(s) is discharged from the hospital.. Payment will be made through a secure link sent to you via text or email. I have read and understand this authorization and consent.*

(Sign here)