Fields marked with an * are required
Email * Name of Pet * Phone Number where you can be reached today: * Preferred Method of Contact: * Procedure being performed: * My pet will not be fed the morning of surgery * If disagree, please explain Will your pet receive medication the morning of the procedure? * Explain Has your pet received any medication within the past 2 weeks? * If yes, medication and when it was given: If your pet needs to go home with medication, are you able to medicate your pet? * I consent to MICROCHIP placement ($78.14) on my pet for permanent identification purposes. * We recommend that a pre-operative ECG to assess cardiac function be performed on your pet prior to anesthesia. The cost for this test is $93.56. * We require pre-operative chest and abdominal X-rays on all pets 7 years of age and older and strongly recommend it for all animals. The cost for the X-rays is $214 * If your pet is here for a DENTAL, do you authorize tooth extractions if deemed necessary? What flavor of polish would you like used? Should EMERGENCY PROCEDURES be necessary and desirable in the attending veterinarian's professional judgement, check ONLY ONE:
All animals entering Park Ridge Animal Hospital must be up-to date on vaccinations and free of external parasites, or they will be treated upon entry at the owner's expense.
I am the owner, responsible agent for, or authorized agent of this animal and I am 18 years of age or older.
I understand the nature of the procedure(s), that there are risks involved with any surgery or procedure, and that no guarantees are made as to the results or cure. I understand that sedation or general anesthesia may be necessary to relieve anxiety during procedures and/or to insure the safety of pets and employees.
I authorize the veterinarians and the staff of Park Ridge Animal Hospital to perform all procedures as set forth in the attached "Estimate," including surgery, medical services, treatment, laboratory tests, x-rays, medications and anesthetics.
This veterinary facility does NOT provide after normal business hours supervision by a person physically on these premises for pets that are treated at this veterinary facility. Your signature on this document confirms that you have been notified of the absence of personnel after normal business hours at this veterinary facility.
I agree to pay in full for services performed including those deemed necessary for medical or surgical complications or unforeseen circumstances and pay a 50% deposit the morning of surgery.
Park Ridge Animal Hospital will use all reasonable precautions against injury, escape or death of my pet, but will not be held responsible in connection with or in any manner, as it is thoroughly understood that I assume all risks.
I have read and understood this authorization and consent
Owner or responsible party *