New Client/Patient Form

ANESTHETIC & SURGERY ADMITTANCE INFORMATION

Client Name*

PrefixFirst NameMiddle NameLast NameSuffix

Primary Contact Phone Number*

This is my:*

Secondary Phone Number

This is my:

Alternate Contact Name

PrefixFirst NameLast NameRelationship

Phone Number

This is a:

My alternate contact is authorized to make medical and financial decisions on my behalf (if no selection is made, only the client listed on record will be authorized to make decisions and pick up the pet).

YES, the person listed as my alternate contact is authorized to make medical & financial decisions and pick up my pet.NO, the person listed as my alternate contact is NOT authorized.NO, the person listed as my alternate contact is NOT authorized to make decisions, but is authorized to pick up my pet.

Pet Name*

Age*

When did your pet last eat?*

Please note date and approximate time

When would you like to pickup your pet?*

Time & Date Preferred

PROCEDURES TO BE PERFORMED

What procedure is being performed today?*

If you selected "other" , please be specific.*

Note "n/a" if other was not selected

Dental Radiographs*

YES, I authorize all dental x-rays the doctor deems necessary.NO, I request a telephone call before the doctor takes any radiographs.My pet isn't having a dental procedure

Dental Extractions*

YES, I authorize all extractions the doctor deems necessary (additional costs apply).NO, I request a telephone call before any extractions are made.My pet isn't having a dental procedure

While my pet is at Firgrove Veterinary Clinic, please:

Is Your Pet Current On Vaccines?*

Are there any other problems with your pet that you would like the doctor to examine and discuss with you?*

If you answered "YES", please explain in detail.

Previous Medical Problems (if none, note as such)*

Current Medications/Supplements (Please include dose & frequency of medication)*

DIAGNOSTICS & FLUID CONSENT

PRE-ANESTHETIC BLOOD TEST CONSENT

Before anesthetizing your pet, we will perform a full physical examination, but in order to detect disorders of the liver, kidneys or other organs, a pre-anesthetic blood test is recommended.*

YES, I authorize my pet to have a pre-anesthetic blood screen (please select from options below)YES, I authorize my pet to have the laboratory tests IF the doctor feels are necessary for the treatment of my pet.NO, I request a telephone call before performing any laboratory tests, except in emergency situations.

Pre-Anesthetic Blood Tests*

Pre-Anesthetic Panel (six chemistries with a CBC for pets under 6yrs of age- $62.50)General Health Profile (twelve chemistries with a CBC for pets over 6 years of age- $84.50)Feline Leukemia-Aids Test For Cats ($39.50)I authorize the doctor to choose whichever test they believe is best for my pet.I declined pre-anesthetic blood testing.

INTRAVENOUS FLUID CONSENT

During most anesthetic, dental and surgical procedures, we recommend that an intravenous catheter to be placed so that intravenous fluids can be administered during the procedure. The fluids will maintain your pet's hydration as well as blood pressure, flow to vital organs and allow your pet to recover from the procedure more quickly. The additional cost of the intravenous fluids is $72.50-$109.50. We require intravenous fluids for some procedures and some pets.*

YES, I authorize the doctor to administer intravenous fluids during anesthesia.YES, I want my pet to have intravenous fluids if the doctor feels this is necessary.NO, I decline intravenous fluids for my pet.

I hereby authorize personnel of Firgrove Veterinary Hospital to administer treatment as is considered therapeutically necessary during the course of hospitalization. I also consent to the administration of such anesthetics and analgesics as are necessary for the diagnostic, medical or surgical procedures to be performed.*

I acknowledge that I have read this statement

I understand that Firgrove Veterinary Clinic is not a 24 hour facility and that I have the right to transfer my pet to a 24 hour facility. Any costs associated with a transfer and the physical transfer of the patient are solely the responsibility of the owner or authorized agent.*

I acknowledge that I have read this statement

ANESTHETIC RISK STATEMENT

Some veterinary procedures need to be preformed with your pet under anesthesia (for example: dentistry, surgery and some diagnostic imaging). Simply put, anesthesia is a controlled unconsciousness, where your pet's level of consciousness is controlled so they don't feel pain and don't move. We certainly don't want our pets to feel pain whenever possible, and it's important that they don't move because precision is required during these procedures and movement could lead to complications. Most healthy pets don't have any problems with anesthesia and, in general, the risks are more closely related to the procedure being done and your pet's general health than to the anesthesia itself. Like any medical procedure, anesthesia does have risks. These risks can run from minor problems, such as vomiting after recovery from anesthesia, to life-threatening problems such as cardiac arrest or stroke. Anesthesia-related deaths are rare, though, and while complications can occur, the veterinary team will take all of the necessary precautions to ensure that your pet is safe and can handle anesthesia. The risks or anesthesia should always be considered along with the benefits, and the risks and benefits of any alternatives to anesthesia should also be considered. In an emergency, life-threatening situation, the risks of anesthesia are usually minimal compared to the risks of not preforming the emergency procedure. For elective procedures, there's more opportunity to postponeanesthesia if some risks that are present can be reduced by treatment prior to the anesthesia and procedure. Most of us are anxious about going under anesthesia ourselves, so it's understandable to be anxious about your pet being anesthetized. Anesthesia for animals has come a long way and is safer than it ever was before, and a well-trained veterinary team further reduces your pet's risk.*

I understand that the planned anesthetic and surgical, diagnostic or therapeutic procedure(s) being preformed today involve risks of complications, injury or even death, both from known and unknown causes and no warranty of guarantee has either been expressed or implied.

I understand that payment for services rendered will be expected in full at time of discharge.*

I acknowledge that I have read this statement

Treatment Plan*

I have NOT received an estimate yetI have already received a verbal estimateI have already received a written estimate

If you have received an estimate already, please note estimated amount given.

If you have received a VERBAL estimate, please note who gave you the estimated amount.

Signature*

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.

Printed Name Of Person Signing*

Date*