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, Inc. 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, credit card, or check 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 PhoneBrief 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:*Vaccination RequirementI 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 First 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 First Elective Procedures to be PerformedElective Procedures to be Performed* Feline Leukemia Test.....$61.74 Pedicure.....$14.73 (30% off regular price) Heartworm Test.....$46.45 Ear Flush.....35.75 (21% off regular price) Microchip Pet Identification.....$65.09 Anal Gland Expression.....$16.23 (18% off regular price) Laser Pedicure.....$45.00 Antibiotic Injection(Convenia).....$ Price Varies Per WeightSignature of Owner or Agent*Date* Date Format: MM slash DD slash YYYY Consent Form for Treatment and/or AdmissionPet's Name* First Species*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, Inc. 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 understand that an estimate of the fees for veterinary services will be provided to me and that I am encouraged to discuss all fees related to such care before services are rendered and during my pet’s ongoing medical treatment. If this pet is hospitalized, I agree to pay a deposit of 50 % of the estimated fees. I agree to assume financial responsibility for the remaining fees and will provide payment via cash, credit card, or check at the time my pet is discharged from the hospital. In the event the pet is hospitalized for more than 48 hours and the attending doctor is unable to reach me, I understand it is my responsibility to call the hospital at least every 48 hours to inquire as to the medical status of my pet and the fees incurred for medical services up to that day.I understand that Anasazi Animal Clinic, Inc. does not have trained personnel on premises for 24-hour observation of my pet.I agree that either I, or an authorized agent of mine, will pick up this pet and pay for all accrued charges within five days of receiving written or oral notification that this pet is ready to be released from the hospital. Such notice will be given at the address maintained on the hospital’s patient/client record. I agree that if I fail to comply with this policy, the hospital may handle this abandonment in a manner that is in the best interests of the pet and the hospital.NameThis 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
