Client InformationOwner's Name(Required) First Last Spouse's Name First Last Address(Required) 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 Phone(Required)Spouse's PhonePet InformationName(Required)Species(Required)Breed(Required)Color(Required)Age(Required)Sex(Required) Male Male – neutered Female Female – spayed Is your pet on any medications or supplements?(Required) Yes No Please list medications and dosages below and when they were last given:(Required)Does your pet have a special diet/food allergies?(Required) Yes No Please list diet, special instructions or allergies below:(Required)Would you like your pet to be updated on vaccines today?(Required) Yes No Please list below (current Rabies required):(Required)A toenail trim is included with SURGICAL procedures at NO COST. If you do NOT want your pet to have a toe nail trim done, please let us know by selecting "no" here: No ** If NOT a surgical procedure and you DO wish for a nail trim, it is an additional cost of $22**If your pet is going home with an e-collar, you have the option of a cone/e-collar or a Buster Body Suit. E-collar: $32 Buster Suit: $55 *e-collars are included with spays/neuters. If you choose a body suit, you will be responsible for the cost difference.***Please be advised Rabies is required – we will administer Rabies if not current or if no proof of vaccination is provided******Please be advised: If your pet is nervous, stressed, anxious or apprehensive to be handled, oral sedation medication may be administered (Trazodone/Gabapenti/Acepromazine) to help reduce their stress.***ALL ANIMALS RECEIVING STERILIZATION SURGERY (SPAY/CASTRATE) WILL BE TATTOOED.YOU MUST BE AVAILABLE TO TAKE CALL(S) FROM DOCTOR WHILE YOUR PET IS HAVING PROCEDURE(S) DONE. WE MAY NEED TO GET FURTHER APPROVAL. IF YOU ARE NOT AVAILABLE BY PHONE, THEN YOU ARE CONSENTING TO FURTHER TREATMENT DEEMED NECESSARY/APPROPRIATE BY THE VETERINARIAN. (you will be liable for further charges)As with any procedure requiring general and/or local anesthesia, there are certain risks that serious complications or even death may result. To minimize the risk of such occurrences, we require baseline bloodwork to be performed in order to assure proper organ function, clotting ability, detect anemia or infection.(Required) I understand and consent that if my female pet (feline/canine/exotics) is coming in for a spay procedure (OVH/OHE) and is pregnant, proceeding with the surgical anesthetic procedure WILL result in termination of the off-spring. (Required) I also understand that No Patient will be given anxiolytic medications at intake if not already given at home. As the owner of the above pet, No Patient, I certify that I am over the age of 18; and I authorize the staff of this hospital to perform the procedure(s) listed above, as well as those deemed necessary to treat life- threatening emergencies. As with all anesthetic, treatment, and/or surgical procedures, I understand there are risks inherent in these services. I acknowledge that staff members at this practice have explained the procedures to me, answered questions to my satisfaction and cannot be held responsible for any unforeseeable results. Further, I understand that I am financially responsible for all costs incurred during this surgery, treatment, and hospitalization.(Required) I certify & Understand the above While I accept that all procedures will be performed to the best of the abilities of the staff at this facility, I understand that veterinary medicine is not an exact science and that no guarantees have been made regarding the outcome of this/these procedures. I have read and understand the nature of the above procedures and accept the specific terms and conditions set forth herein.(Required) I have read & understand Should unexpected life-saving emergency care be required I would like the hospital staff to attempt the following life-saving measures (select one):(Required) Closed Chest Resuscitation including drugs, CPR, defibrillation, and assisted breathing PLEASE BE ADVISED THIS MAY ADD A MINIMUM OF $250 (FOR FIRST 5-10 MINUTES) IN ADDITION TO THE PREVIOUS CHARGES. Do NOT attempt resuscitation (Required) I acknowledge that I am responsible for payment in full for the above procedures and treatments at the time my pet is discharged. Signature(Required)Date(Required) MM slash DD slash YYYY CAPTCHA Δ