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: ______