|Today's Date: (required)
|First & Last Name: (required)|
|Best Phone/Contact Number: (required)|
|Email Address: (required)|
|Secondary Contact Information (Phone, email):|
|Pet's Name: (required)|
|Reason for Admission: (required)|
|Date of procedure: (required)
I certify that I am the owner, or authorized agent for the owner of the pet named above. I understand my pet will be undergoing a procedure requiring general anesthesia today, and do hereby give my consent and authorize Navarre Animal Hospital and it's staff to hospitalize this pet and perform the above described procedure(s) necessary for it's health, safety and well-being.
I have been advised as to the nature of the procedure(s) and the potential risks, including death, and understand the reason why such medical and/or surgical treatment is considered necessary, as well as its advantages and possible complications, if any. I also understand that no guarantee of successful treatment or outcome can be made.
Pre-Anesthetic Blood Work
|We recommend blood work prior to anesthesia in order to screen for major organ dysfunction and potential greater anesthetic risk. This is required if your pet is 7 years or older. (required)|
I DO want pre-anesthetic blood work for my pet
I DECLINE pre-anesthetic blood work for my pet
My pet is 7 years or older and I understand pre-anesthetic blood work is REQUIRED
Elizabethan Collar or Medical Pet Shirt
|If you have an e-collar or medical pet shirt at home you can bring it with you upon your pet's admission. We require your pet to wear an e-collar and/or medical pet shirt. for 7-14 days to protect their incision from trauma caused by licking or chewing. (required)|
I DO want an elizabethan collar
I DO want a medical pet shirt
I will bring my own collar/pet shirt with me that morning
|This is a permanent form of identification implanted under your pet's skin and can be done during your pet's procedure. (required)|
I DO want to microchip my pet
I DECLINE to microchip my pet
My pet is already microchipped
I understand that it is impossible to accurately estimate the total charges involved as the total extent of the injuries or illness may not be immediately present. The results of blood tests, urinalysis, radiographs, etc. may be needed before the doctor can approximate a total expense. I also understand it is impossible to accurately estimate the time and individual animal needs to respond to a treatment plan and this factor may affect the total cost.
I would like Navarre Animal Hospital to contact me if additional treatment is needed that exceeds the estimated range. I understand an updated treatment plan and estimate will be provided with my permission obtained to proceed should I be available. I understand and plan to have a phone number which Navarre Animal Hospital can contact me or an authorized agent for my pet any time on the day of the procedure.
If we CANNOT reach you...
I understand that if the staff at Navarre Animal Hospital is not able to reach me, I consent to and authorize the performance of such procedures as are necessary in the judgment of the attending veterinarian.
I have read & agree to all of the above
|Signature (Please type your first & last name): (required)|