"*" indicates required fields Thank you for entrusting your pet’s care to us today. The following information will be used to help our veterinary team accurately complete your pet’s medical history for their visit. We ask that you provide this information 24 hours in advance. Client Name* First Last Patient Name* First Last Phone number at which owner can be reached today:*Additional number*Would you like us to text you after the procedure, or would you prefer a call?* Text Call Requested Procedure(example: spay, neuter etc.)If a dental procedure is scheduled, extractions may be deemed necessary. This service is provided at an additional fee. Would you like to authorize extractions or would you prefer to be contacted prior? Yes No Do you want to be called if there will be tooth extractions? Yes No if yes in the event that I cannot be reached, I give permission to proceed with extractions deemed as medically necessary by the doctor Yes No I, the undersigned owner or agent of the pet identified above, hereby request and authorize the staff of Memorial Veterinary Clinic to perform the above procedure(s). I consent to and authorize the performance of such as necessary in the veterinarian’s professional judgment.* I have read and agree Microchip: *There is an additional fee for this procedure* Yes No Already has one Have you given your pets any medications or supplements in the past week? Yes No Other medication When was the last time fed? Any other concerns/allergies/procedures? I understand that I will be speaking with a nurse prior to admitting my pet to Memorial Veterinary Clinic, which can take up to ten minutes. I understand that there is a scheduled admission and pick up time.* I have read and agree I authorize the Veterinarian to administer anesthesia and pain relief medication as needed before and/or after the procedure. I understand that there are risks associated with the use of any medication. I also understand that there are certain risks and complications associated with any operation or procedure of this type, including death of my feline(s) or canine(s). I acknowledge that I have had the opportunity to speak with a Memorial Veterinary Clinic licensed veterinarian about the risks and complications associated with the above listed procedure(s).* I have read and agree Memorial Veterinary Clinic strives to practice high quality medicine at all times. All patients will receive a thorough physical examination before anesthesia. We use the safest anesthesia available, however to further minimize risk during anesthesia we will perform pre-anesthetic labwork, place an intravenous (IV) catheter, and administer IV fluids on all procedures. This screening is similar to those used in the human hospitals, and is used to ensure that your pet has no hidden medical problems not detectable on the physical examination. The tests we run include a CBC (complete blood count) and chemistry profile (internal organ function) if not already completed in the last thirty days.* I have read and agree I am over 18 and understand that the attending veterinarian will make every effort to contact me regarding treatment in the case of unforeseen emergencies. If unable to contact me, I agree that In the event my pet experience a cardiac, respiratory or other life-threatening emergency that requires resuscitative or other urgent care measures, such as cardiopulmonary resuscitation (CPR), positive pressure ventilation, emergency drugs, or other similar measures, I request that the veterinarians and/or trained staff at Memorial Veterinary Clinic pursue such medical care as indicated below.* Resuscitate (R): I authorize emergency treatment if the situation arises (including cardio pulmonary resuscitation (CPR) and other life-saving treatments) and understand this may result in additional charges and I agree to pay for these emergency and life-stabilizing treatments even if they exceed any estimate I may have been provided. Do Not Resuscitate (DNR): I do NOT authorize emergency treatment if the situation arises (including cardio pulmonary resuscitation (CPR) and other life-saving treatments) and prefer to be contacted before any additional treatment is performed. I understand that per clinic policy my animal(s) must be current on rabies vaccine, distemper, adenovirus 2, parvovirus and parainfluenza vaccine (for canines only), a feline viral rhinotracheitis, calicivirus and panleukopenia vaccine (for felines only). Vaccination services may be waived only if current vaccine proof is received at the time of check in, or at the discretion of the veterinarian on a case by case basis.* I have read and agree While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, Iunderstand that no guarantee or warranty has been made regarding the results that may be achieved. I alsoassume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow up radiographs, re-check physical exams and additional surgery due to post-op complications. Though complications can occur naturally on rare occasions, they are much more likely to occur when there is a failure to comply with post-operative instructions sent home on the day of surgery. I have been provided an estimated cost for the procedure(s) listed above. I assume financial responsibility for the recommended services and will provide payment in full at the time my pet is discharged from the hospital. I have read and fully understand the terms and conditions set forth above.* I have read and agree I RELEASE MEMORIAL VETERINARY CLINIC, VETERINARIAN, VETERINARY TECHNICIANS, AND THEIR RESPECTIVE SUCCESSORS, ASSIGNS, AGENTS, AND VOLUNTEERS FROM ANY AND ALL CLAIMS, CAUSES OF ACTION, DAMAGES, OR LOSSES OF ANY KIND ARISING FROM OR RELATING TO THE PROVISION OF VETERINARY CARE, INCLUDING, BUT NOT LIMITED TO, THE PERFORMANCE OF SURGICAL PROCEDURES, AS WELL AS ANY ADVERSE REACTIONS FROM VACCINATIONS OR MEDICATIONS. THIS RELEASE IS INTENDED TO RELEASE ALL NEGLIGENT ACTS OR OMISSIONS. I AGREE TO INDEMNIFY AND HOLD HARMLESS THE INDIVIDUALS OR ENTITIES DESCRIBED IN THIS PARAGRAPH FOR ANY DAMAGES CAUSED BY MY ANIMAL(S) WHILE IN THE CARE OF Memorial Veterinary Clinic OR VETERINARIAN.* I have read and agree Signature*Date* MM slash DD slash YYYY
