Fields marked with an * are required

Name *

First

Last

Email *

Name of Pet *

Phone Number where you can be reached today: *

Preferred Method of Contact: *

Phone call
Text
Email

Procedure being performed: *

My pet will not be fed the morning of surgery *

Agree
Disagree

If disagree, please explain

Will your pet receive medication the morning of the procedure? *

Yes
No

Explain

Has your pet received any medication within the past 2 weeks? *

Yes
No

If yes, medication and when it was given:

If your pet needs to go home with medication, are you able to medicate your pet? *

Yes
No

I consent to MICROCHIP placement ($78.14) on my pet for permanent identification purposes. *

Yes
No

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. *

I authorize this test.
I DECLINE this test

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 *

My pet is 7 or older, I understand this test is required
I authorize this test
I DECLINE this test (NOTE: you cannot decline chest x-rays if your pet is 7 years or older)

If your pet is here for a DENTAL, do you authorize tooth extractions if deemed necessary?

Yes
Please call me first, but if I cannot be reached, proceed as medically advisable.
Do not perform any extractions, even if deemed necessary by a veterinary professional

What flavor of polish would you like used?

Bubble Gum
Cherry
Mint

Checkboxes *

I understand that whenever anesthesia is given or a pet undergoes a surgical/dental procedure, some risk is involved. The amount of risk depends on many factors, including age, general physical condition, and the condition of the heart and internal organs. At Park Ridge Animal Hospital we make every effort to minimize this risk, however, we cannot guarantee that a problem will not occur. *

Should EMERGENCY PROCEDURES be necessary and desirable in the attending veterinarian's professional judgement, check ONLY ONE:

I authorize Park Ridge Animal Hospital to proceed with all procedures. I agree to assume full financial responsibility for those procedures.
I prefer to be contacted by phone prior to any additional procedures. If I cannot be reached, I authorize unforeseen procedures and assume financial responsibility for those procedures.
If I cannot be reached, I do not authorize unforeseen emergency or life-threatening procedures.

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

Date

Owner or responsible party *

Surgical Admissions Form

Authorization and consent for professional services

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