Anesthesia and/or Surgery Authorization Form Owner's Name(Required) First Last Phone(Required)Pet's Name(Required)Email(Required) Today's Date(Required) MM slash DD slash YYYY Allergies:(Required)Anesthetic/Surgical Procedure:(Required)I have received a treatment plan for my pet(s) procedure.(Required) Yes No Has your pet shown any signs of the following? (Check all that apply)(Required) Vomiting Diarrhea Sneezing Lethargy Coughing None of the above If yes, for how long?(Required)If yes, for how long?(Required)If yes, for how long?(Required)If yes, for how long?(Required)If yes, for how long?(Required)Pet must arrive between 7-8 am unless otherwise directed.(Required) Accept My pet(s) should not eat after 10pm the night before their procedure.(Required) Accept Has your pet ever been anesthetized? If yes, did your pet have any complications?(Required)Has your pet been on any medications in the past 30 days? Please List and list the last done given.(Required)Options:If your pet is not already microchipped (a permanent form of identification), now may be a good time to have it done. Although microchipping does not require anesthesia, it may be easier for some pets to have the chip implanted while asleep. Please note the cost is in addition to anesthesia/surgery charges.(Required) Accept Decline Already performed If your pet is undergoing a dental cleaning or is determined to have retained baby teeth at time of anesthesia, it may be determined that extractions are necessary. If an extraction is recommended every attempt will be made to contact you. In the event you cannot be contacted:(Required) You approve extraction(s) and additional charges Decline extractions without verbal approval Country Friends now offers the option for us to apply a tattoo to easily identify whether your pet has been spayed or neutered. Please note the cost is in addition to the anesthesia/surgery charges. Please mark Accept or Decline if you would like for us to apply a small indicator tattoo while your pet is under anesthesia.(Required) Accept Decline Should unexpected life-saving emergency care be required and the hospital is unable to reach you, the staff of Country Friends - 1. HAS 2. DOES NOT HAVE - your permission to provide such treatment at additional cost to you.(Required) Has Does not have I hereby authorize the veterinarians at Country Friends Veterinary Clinic to perform such diagnostic, treatment and/or surgical procedures as deemed necessary for my pet. The nature and risk of the procedure(s)have been explained to me and no guarantee has been made as to the results or cure. I fully understand that there may be risk and the potential for complications including death to such procedures. I agree to pay, in full, for services rendered including those deemed necessary for medical or surgical complications or otherwise unforeseen circumstances. All animals admitted must be current on vaccinations and be free of external parasites. Animals not in compliance with the above policy will be treated at owner’s expense. Any estimate of charges or fees for presently planned procedure(s) is only a best approximation and the final bill may be greater or less than this amount. I have read the above conditions for treatment and acknowledge that I may have a copy of this form, if requested.(Required) I have read and understand FULL payment of ALL procedure(s) on (or not on) this treatment plan, is due on the date or at the time of the patient release. Our office accepts Visa, Mastercard, Discover, AMEX, and Cash. Our financing options are Scratch Pay, Care Credit, and Payment Banc. **Clients with payment concerns are asked to speak with a Client Service Representative prior to any services/treatment.**(Required) Yes, I need financing options. No, I do not need financing options. Best number(s) to reach you today:(Required)Owner/Agent’s Signature:(Required)Today's Date(Required) MM slash DD slash YYYY CAPTCHANameThis field is for validation purposes and should be left unchanged.
