Client NameAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhonePet NameSpeciesBreedSexColorDate of BirthHas you pet been fasted? Yes No Your pet will receive a mini blood profile before anesthesia and surgery. The latest technology lets us run safe, accurate blood chemistries minutes before induction. These tests are similar to those your own physician would run were you to undergo anesthesia. In addition, the results will serve as reference values for future use should your pet become ill. Pain medication is required for all patients undergoing surgery. It can be sent home with your pet, at an additional cost, if needed. I, the undersigned, authorize Pain Management to take home after surgery for my pet. (Cost will vary due to size of pet)SignatureI, the undersigned, being responsible for the above described animal, have the authority to grant you my consent to receive, prescribe for, treat and/or operate upon my pet. You are to use all reasonable precaution against injury, escape or death of my pet, but you will not be held liable or responsible in any manner in connection therewith as it is thoroughly understood that I assume all risks. I understand that the use of anesthesia is required by the treatment plan. I understand that there are certain risks to anesthesia that could involve serious bodily injury or death and that these risks are present in any procedure that requires a general, intravenous or intramuscular anesthetic. I consent to the use of anesthesia as deemed necessary and advisable in the professional judgment of the veterinarian. After carefully reading the above, I have signed in agreement below:SignatureDate MM slash DD slash YYYY Δ
