<p> GREEN SUMMIT ANIMAL CLINIC Treatment / Surgical Release</p><p>Patient: ______Species: K-9 Feline Other ______</p><p>Client Name: ______Phone: ______</p><p>Age: ______Sex: M MN F FS Breed / Markings: ______</p><p>EXAM Procedure: ______</p><p>Current Medications: ______SID_____BID______TID______AM______PM______SID_____BID______TID______AM______PM______</p><p>I WOULD LIKE THE FOLLOWING TESTS PERFORMED ON MY PET PRIOR TO ANESTHESIA:</p><p>Bloodwork:______Radiographs:______Urinalysis:______Roll Swabs:______T4:______Ear Flush:______</p><p>IN ADDITION I WOULD LIKE THE FOLLOWING SERVICES PERFORMED ON MY PET:</p><p>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</p><p>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.</p><p>I understand the hospital policies and authorize Green Summit Animal Clinic to proceed with treatment, services, and/or surgery.</p><p>Signature of Pet Owner or Agent:______Date:______</p><p>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.</p><p>Signature of Pet Owner or Agent:______Date:______</p><p>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.</p><p>Belongings:</p><p>Collar: ______Leash: ______Staff: ______</p>