Surgical Information Packet

I, the undersigned owner or agent of the owner of the pet identified above, certify that

eighteen 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 pet
• Sufficient details of the procedures to understand what will be performed
• How fully my pet will recover and how long it will take
• The most common and serious complications
• The length and type of follow-up care and home restraint required
• The estimate of the fees for all services
• Any necessary payment arrangements

While 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

my 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.

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.

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.

I, the undersigned owner, agent of the owner of, or Good Samaritan responsible for seeking veterinary care for the pet identified above, certify that

eighteen 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.