Email(Required)

Pet's Name(Required)

Breed(Required)

Age/Date of Birth(Required)

Service(s) to be Performed(Required)

PATIENT HISTORY:

If yes, please list(Required)

If yes, please explain(Required)

If yes, for how long?(Required)

If yes, please explain(Required)

When was the last time your pet ate?(Required)

When was the last time your pet was in heat or bred?(Required)

*** There is an increased risk with spaying female pets whom have been in heat within the past 8 weeks. It takes roughly 6-8 weeks for the blood vessels to return to a normal (smaller) size after estrus bleeding has begun. If you choose to proceed, we will take as many precautions as needed but this may lead to an increased cost as shown on your estimate. Post operative complications, including hemorrhage and delayed healing, are possible.***

OTHER SERVICE(S) TO BE PERFORMED:

VACCINATION CONSENT:

Please Specify:

ELIZIBETHAN COLLAR:

CALMING MEDICATION:

PRE-ANESTHETIC BLOOD WORK:

PAIN/INFLAMMATION RELIEF CONSENT:

POST OPERATIVE EMESIS:

PHOVIA TREATMENT:

HISTOPATHOLOGY SUBMISSION:

ANESTHETIC MONITORING:

IV CATHETER:

I am the owner or the authorized agent for the owner of the animal described above, and I have the authority to execute this consent. My signature below certifies that I am over eighteen years of age.

Pondview reserves the right to treat my pet for fleas, ticks, lice, earmites, or worms if found during routine examination or during the procedures listed above.

If overnight supervision is required and I elect to pick up my pet and provide care in my home, I accept all risks of adverse effects. I am aware that I have the choice to transfer him/her to a local emergency clinic where overnight veterinary supervision is available at my expense.

I am aware that the practice of veterinary medicine is not an exact science and, thus, there are no guarantees for successful treatment. I have been informed that there are certain risks and complications associated with sedation, anesthesia, and/or any operation/procedure and that the risks/complications have been explained to me. I further understand that during the course of the operations or procedures, unforeseen conditions may arise that may necessitate the performance of additional procedures deemed necessary by the veterinarian. I am encouraged to discuss any concerns I have about these risks with the attending veterinarian. I accept that my financial obligations remain regardless of the outcome and payment is due at time of patient discharge.

I am aware that payment is required at the time of service and due upon checkout. Treatment of my animal is determined by my decisions, with consideration of my financial resources. If any charges are not paid when due, interest will accrue at 2.0% per month. Any collection expenses, including attorney fees, are my (the owner's) responsibility. Pondview Veterinary Clinic accepts the following types of payment: cash, check, Visa, Mastercard, American Express, Discover, Care Credit and Scratch Pay.

I have read and understand this authorization and hereby accept and agree to the terms of the consent for treatment.

AUTHORIZED BY(Required)

Date(Required)

CONTACT NUMBER WHILE YOUR PET IS AT THE CLINIC(Required)

CPR Consent

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Phone

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Canine Surgical Consent Form