Client Details

Name *

First

Last

Has recently? as

Address *

Address Line 1

City

State

Zip Code

Phone *

Email *

Animal Details

Name *

Species *

Breed *

Age *

Sex *

Male
Neutered Male
Female
Spayed Female

Weight (lbs) *

Your pet has been admitted for: *

Best number to be reached today for unexpected changes to the procedure: *

Additional phone number if you aren't able to be reached: *

If I am unable to be reached while my pet is under anesthesia, I consent for the veterinarian in charge to make the necessary medical decisions as needed. This may include extractions and/or additional medications and would incur additional costs of up to $500.00. *

Yes
No

In the event that my pet’s heart stops while at the hospital, I would like the medical team to: *

CPR (Cardiopulmonary Resuscitation): I authorize the veterinary team to perform life-saving measures such as chest compressions, medications, and/or intubation to try to restart my pet’s heart and breathing.
DNR (Do Not Resuscitate): I do not want resuscitation efforts to be performed. I understand that this means the medical team will allow natural death to occur without intervention.

Has your pet eaten after 8 PM last night? *

Yes
No

Time and Amount *

Has your pet had any medication recently? *

Yes
No

Mediation/Dose/Time Given *

If anesthesia/sedation is required, I understand that there are risks involved and that in the event of an emergency, the hospital will take all necessary actions to control the problem and will notify me as soon as possible.

The estimated cost of these procedures is ($)

I fully understand that this is an estimate only. On-Site Veterinary makes every effort to remain within the estimate given.

I agree to meet the costs of all treatment at the time of discharge. I understand the risks and complications of these procedures, which have been explained to me by the Veterinarian.

All accounts are payable at the time of consultation unless a prior arrangement has been made.

Signature (Owner/Responsible Party) *

Clear Signature

Procedure Consent Form

Client Details

Animal Details

If anesthesia/sedation is required, I understand that there are risks involved and that in the event of an emergency, the hospital will take all necessary actions to control the problem and will notify me as soon as possible.

All accounts are payable at the time of consultation unless a prior arrangement has been made.

Ready to Visit?

Location

Contact Information

Hours

Emergencies

Have a Question?

Procedure Consent Form

Fill Out Our Procedure Consent Form

Client Details

Animal Details

If anesthesia/sedation is required, I understand that there are risks involved and that in the event of an emergency, the hospital will take all necessary actions to control the problem and will notify me as soon as possible.

All accounts are payable at the time of consultation unless a prior arrangement has been made.