Surgical Information PacketStep 1 of 333%Authorization for Anesthesia and/or SurgerySpay, Neuter, Dental or Declaw ProceduresName* First Last Pet's Name* Pet's Name Anesthetic and surgical procedure(s) to be performed*I, the undersigned owner or agent of the owner of the pet identified above, certify that*I amI am noteighteen years of age or over and authorize the veterinarian(s) at Anasazi Animal Clinic to perform the above procedure(s). I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. My signature on this form indicates that any questions I have regarding the following issues have been answered to my satisfaction:The reasonable medical and/or surgical treatment options for my petSufficient details of the procedures to understand what will be performedHow fully my pet will recover and how long it will takeThe most common and serious complicationsThe length and type of follow-up care and home restraint requiredThe estimate of the fees for all servicesAny necessary payment arrangementsWhile I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I agree to pay a deposit of 50 % of the estimated fees, assume financial responsibility for the remaining fees, and provide payment via cash or credit card at the time my pet is discharged from the hospital. Should unexpected life-saving emergency care be required and the hospital staff is unable to reach me, the staff*hasdoes not havemy permission to provide such treatment and I agree to pay for such services.I have read and fully understand the terms and conditions set forth above.Signature of Owner or Agent*Date* Date Format: MM slash DD slash YYYY Signature of Parent or Legal Guardian*Date* Date Format: MM slash DD slash YYYY Contact Information*Phone number(s) at which owner or agent can be reached today and/or tomorrowHome Phone*Cell PhoneWork PhoneHow Did You First Become Aware Of Our Clinic?How Did You First Become Aware Of Our Clinic?Personal RecommendationAnasazi WebsiteDexonlineYellow PagesPrevious ClientEmergency Hospital or other VetAnimal Care & ControlDrove ByPet StoreYelpOtherWhom Should We Thank?Brief HistoryDoes your pet have any history of trauma?*YesNoDoes your pet have any history of illness?*YesNoIs your pet allergic to any medications?*YesNoIs you pet currently taking any medications, including asprin?*YesNoHave you noticed a change in your pet’s appetite/activity level?*YesNoPlease explain any “YES” answer(s) to the above questions:*Other Major Medical IssuesVaccination RequirementIs your pet's rabies vaccine current?*YesNoOther should only be used in the case that the animal has been rescued or found, etc. If other, please specify the situation.I understand that a rabies vaccine is required and must be up to date. I can and will provide written evidence of a current rabies vaccination. This is necessary to provide documentation in case your pet bites another animal or person while at this veterinary clinic.Approve Rabies Vaccination Client Initials I understand that a rabies vaccine is required and must be up to date. I can and will provide written evidence of a current rabies vaccination. This is necessary to provide documentation in case your pet bites another animal or person while at this veterinary clinic.Decline Rabies Vaccination Client Initials Elective Procedures to be PerformedElective Procedures to be Performed Feline Leukemia Test Pedicure Heartworm Test Ear Flush Microchip Pet Identification Anal Gland Expression Laser Pedicure Antibiotic Injection(Convenia)Previous Veterinarian*Reason for Visit*Duration of ProblemAppointment Date* Date Format: MM slash DD slash YYYY Appointment Time* : HH MM AMPM Signature of Owner or Agent*Date* Date Format: MM slash DD slash YYYY Consent Form for Treatment and/or AdmissionPet's Name* First Species*Breed*Sex*I, the undersigned owner, agent of the owner of, or Good Samaritan responsible for seeking veterinary care for the pet identified above, certify that*I amI am noteighteen years of age or over. I consent to the examination of this pet by staff veterinarians at Anasazi Animal Clinic. I also agree that after consultation with me, the hospital’s doctors may prescribe medication for, treat, hospitalize, sedate, anesthetize, and/or perform surgery on my pet. I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure is initiated. Should unexpected life-saving emergency care be required and the attending veterinarian is unable to reach me, the hospital staff has my permission to provide such treatment, and I agree to pay for such care.I authorize and direct the veterinarians at Anasazi Animal Clinic to examine, diagnose, prescribe, perform therapeutic procedures, and/or surgery that their judgment may dictate to be advisable for the patient’s well being. No warranty or guarantee has been made as to the result or cure. ALL FEES ARE REQUIRED TO BE PAID IN FULL UPON COMPLETION OF THE VISIT. We accept cash, all major credit cards, Synchrony CareCredit, WellsFargo Financing and Scratch Pay with the required identification. A deposit is required at the time of admission and the balance paid in full at discharge. If you have any questions about the fees or the financial policy, please alert a staff member before services are performed. If for some reason there is a balance on the account it must be paid in full within 30 days of patient visit. Any accounts not paid in 30 days are subject to an interest finance charge. In the event any balance due is not paid as agreed, the undersigned jointly and severally agrees to pay all cost included in the unpaid balance, including a reasonable collection and /or attorneys’ fees.I hereby irrevocably consent to the use of any images of my pet, taken by Anasazi Animal Clinic, in any and all marketing or teaching materials.*YesNoWhen drugs are FDA-approved for use in one species but are administered to species other than those for which they have been approved and labeled, the terminology is that the drugs are being used in an “extra-label” manner. Extra-label use does NOT include the use of experimental drugs or drugs manufactured in foreign countries that have not been approved by the FDA. Because few drugs are labeled for use in small animals, most drugs administered by small animal or exotic animal veterinarians, including antibiotics, anesthetic agents, and other medications, are routinely used in an extra-label manner. This is within the standard of care, but good medical practice requires that owners be advised when drugs are being used in an extra-label manner.* I authorize the staff at this veterinary practice to administer and prescribe extra-label drugs for my pet. I understand that any drug, including those that are used in an extra-label manner, can produce undesirable side effects. Thus, I acknowledge that it is my responsibility to administer prescribed medications for my pet as directed and to notify my veterinarian of any apparent side effects or complications.CommentsThis field is for validation purposes and should be left unchanged.Compassionate Care For All PetsWe are passionate about providing excellent care for all pets.Schedule an Appointment
