Authorization for Anesthetic Procedure Spay/Neuter



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Dripping Springs Animal Hospital

1520 E. HWY 290

Dripping Springs, TX 78620

Phone: 512-858-4787

Fax: 512-858-4396


Authorization for Anesthetic Procedure - Spay/Neuter
Date: ____________________


Client's Name:



Patient's Name:





Primary Contact Number Today: _______________________________________________________
Secondary Contact Number for Today: __________________________________________________
What is the earliest time you are available to pick up your pet today?_________________________

(your pet may not be ready to go home by this time).
Anesthetic or surgical procedure(s) to be performed: ______________________________________
What other procedures/services do you want performed today? _____________________________
I, the undersigned owner or agent of the owner of the pet identified above, certify that I am of eighteen years of age or over and authorize the veterinarian(s) at this practice to perform the above procedure(s). I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. My signature on this form indicates that any questions I have regarding the following issues have been answered to my satisfaction:

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that veterinary medicine is not an exact science and that no guarantee or warranty has been made regarding the results that may be achieved. I agree to pay the estimated fees, assume financial responsibility for the remaining fees, and provide payment in full at the time my pet is discharged from the hospital. Should an unexpected critical situation arise (choose one):


 I authorize and accept financial responsibility for the veterinarian(s) and staff to perform lifesaving procedures.
 I choose that the veterinarian(s) and staff DO NOT resuscitate my pet.

Authorization for Treatment Beyond Estimate


I understand that fees beyond the estimate for this procedure may result if it is found that my pet is in heat (females) or cryptorchid/retained testicles (males).

Authorization to Remove Deciduous Teeth
Occasionally while under anesthesia deciduous teeth are found in pets that are in need of extraction in an attempt to avoid future procedures. (choose one)
 I authorize deciduous teeth to be pulled if necessary.
 I do not authorize deciduous teeth to be pulled and understand that the need for a future anesthetic procedure may result.
Microchipping
Microchipping is the most permanent Pet Identification system available today. Often the best time to place a microchip is when the pet is under anesthesia so the pet does not have to feel the pain of the larger than average needle.
Would you like to have your pet microchipped during this procedure?
 Yes
 No

I have read and understand the nature of the above procedures and give my consent to proceed.










Signature of Owner or Authorized Agent




Date

____________________________________________________________________________________



Office Use Only- Completed by:____________


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