Green Summit Animal Clinic

GREEN SUMMIT ANIMAL CLINIC Treatment / Surgical Release

Patient: ______Species: K-9 Feline Other ______

Client Name: ______Phone: ______

Age: ______Sex: M MN F FS Breed / Markings: ______

EXAM Procedure: ______

Current Medications: ______SID_____BID______TID______AM______PM______SID_____BID______TID______AM______PM______

I WOULD LIKE THE FOLLOWING TESTS PERFORMED ON MY PET PRIOR TO ANESTHESIA:

Bloodwork:______Radiographs:______Urinalysis:______Roll Swabs:______T4:______Ear Flush:______

IN ADDITION I WOULD LIKE THE FOLLOWING SERVICES PERFORMED ON MY PET:

Rabies _____ DHLPP4i _____ No Lepto _____ LEPTOB _____ Bordi _____ Bord Sq ______Fecal _____ HWT _____ FVRCP _____ LEUK _____ BORDC _____ TNT _____ Deworm______A/G _____ Paid Bath: ______Feline Convenia Shot ______or Pill _____ T/D Yes or NO

HOSPITAL POLICIES:  All hospitalized animals must be current on vaccinations.  All hospitalized animals must be free of internal and external parasites.  An IV Catheter with fluids is required with all anesthetic procedures.  When necessary, pain management is required and will be charged to the client.  Aggressive animals will be charged a minimum of an additional $27.31.  Estimates of charges are given upon request. All costs incurred may not be included in the estimate as there may be unanticipated expenses.  Payment in full is required unless prior arrangements have been made with the Practice Manager.  All costs of collection, court costs, and attorney fee’s will be paid by the client.

I understand the hospital policies and authorize Green Summit Animal Clinic to proceed with treatment, services, and/or surgery.

Signature of Pet Owner or Agent:______Date:______

I have elected to decline the optional recommendations for pre-anesthetic safety as listed above, fully understanding that the lack of such tests increases the potential risk. Should complications arise during anesthesia, I shall not hold the doctors or staff of Green Summit Animal Clinic liable and I will assume full financial responsibility.

Signature of Pet Owner or Agent:______Date:______

I authorize Green Summit Animal Clinic to release my pet to: ______I understand my bill must be paid in full prior to the release of my pet.

Belongings:

Collar: ______Leash: ______Staff: ______