Pet Information

Pet's Name*

Contact Information

Owner's Name*

First Last

Email*

Phone*

When did your pet last eat?*

When was your pet's last heat cycle (if applicable)?*

Today's procedure is: (example: lump removal, exam, etc.)*

Teeth Cleaning Procedure Questions: If your pet is having a teeth cleaning performed today and extractions are needed, we will call you with an updated estimate. If we cannot reach you within 5 minutes, do we have permission to proceed with extractions in the best interest of your pet? Please note that additional costs involved will be due to anesthesia time, tooth removal and medications.

Choose what is applicable

Yes, you have permission to extract teeth as necessary

No, do not extract teeth (pet will be woken up from anesthesia)

Did you receive a treatment plan estimate for today’s procedure(s)?

Yes

Additional Services Desired While Patient Is Sedated

Please select any/all that you would like us to provide while your pet is sedated

Implant Microchip

Nail Trim

Clean Ears

Express Anal Glands

Sanitary Clip (rectum, genitals)

Remove Lumps (specify location of lumps below)

Other (specify below)

Please specify where the lumps are located*

Please specify the additional service(s) you'd like provided to your pet*

Pain management consent: If your pet will be having a painful procedure that the doctor feels warrants pain control, we reserve the right to administer appropriate pain management in the hospital at an additional charge. Prescription pain mediation may be sent home upon release.

Blood work and anesthesia consent: Your pet is scheduled to have a procedure today that requires anesthesia. Although blood testing has been done to screen the vital organs that remove anesthetic from the body, it is important to understand that the pre-anesthetic blood profile does not guarantee the absence of complications.

Electronic Agreement: By typing my full name (first name and last name) below, I hereby authorize the Animal Hospital of Shawnee Hills to perform the above listed procedure(s) with associated anesthesia. I am aware of the risks involved and will not hold the Animal Hospital of Shawnee Hills or its staff liable in any manner whatsoever or under any circumstances. I acknowledge that no guarantee or assurance has been made as to the results that may be obtained.

Full payment is required at the time services are provided (we are not able to provide billing services). Due to the COVID-19 Pandemic, we can only accept credit card payment over the phone, including, Visa, MasterCard, Discover Card, Care Credit, & American Express. I understand that the hospital staff will provide an estimate of current and anticipated charges before services are rendered and that I am financially responsible for all services provided.

Signature*

Date*

Authorization

I authorize anesthesia/sedation for my pet. The nature and risks of this procedure have been explained to me. I understand some risks always exist with anesthesia and/or sedation, and I am encouraged to discuss any concerns I have about those risks with my veterinarian before the procedure(s) are initiated. My signature on this consent form indicates that any questions have been answered to my satisfaction.*

I have read, understand, and authorize

I authorize Animal Hospital of Shawnee Hills to perform any additional diagnostic, treatment, or surgical procedure(s) deemed necessary for medical complications or otherwise unforseen circumstances. I understand there are rare complications associated with any anesthetic procedure. No warranty or guarantee has been given to me as to the results or cure afforded by these treatments or procedures. I fully understand these risks and understand the veterinarians and hospital staff will try to minimize such risks. I will not hold Animal Hospital of Shawnee Hills, the veterinarians, or any staff member liable for any complications that may arise.*

I have read, understand, and authorize

Payment due upon services rendered.*

I have read, understand, and authorize

I HAVE READ AND FULLY UNDERSTAND THIS ANESTHESIA CONSENT FORM*

Yes

Signature of Responsible Party*

Date*

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Name

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Surgical Anesthesia Release Form