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Anesthesia Authorization Form
Owner's Name
(Required)
First
Last
Phone
Pet's Name
(Required)
Email
(Required)
Today's Date
(Required)
MM slash DD slash YYYY
Allergies:
(Required)
Anesthetic/Surgical Procedure:
(Required)
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
Has your pet eaten this morning?
(Required)
Yes
No
Has your pet ever been anesthetized? If yes, did your pet have any complications?
Has your pet been on any medications in the past 30 days? Please List and list the last done given.
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.
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:
You approve extraction(s) and additional charges
Decline extractions without verbal approval
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.
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.
I have read and understand
All fees for services are due when patient is released.
I have read and understand
Best number(s) to reach you today:
Owner/Agent’s Signature:
(Required)
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Today's Date
(Required)
MM slash DD slash YYYY
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Phone
This field is for validation purposes and should be left unchanged.
