AUTHORIZATION FOR CANINE/FELINE MEDICAL OR SURGICAL TREATMENT

DENTISTRY FORM

Owner’s Name ______, ______

(Last)(First)

Pet’s Name ______

Where can we reach you today?______until ____:____ Alternate # ______until ___:___

Procedure(s) to be performed today ______

HISTORY

Yes No Yes No

  Are vaccinations current?   Has your pet had any illness or injury in the last 30 days?

  Is your pet on heartworm prevention?   Is your pet currently on any medications?

  Did your pet eat this morning?   Has your pet ever had any seizures?

    Would you like to have your pet microchipped today?

Due to decay or gum disease, it is sometimes necessary to extract teeth.

Yes No

  Are you authorizing extractions?

PAIN MEDICATION

Depending on the procedure, your pet may experience significant pain or discomfort for several days.

Yes No

  Would you like pain medication to take home?

PRE-SURGICAL BLOOD SCREEN

Dupont Veterinary Clinic performs a pre-surgical blood chemistry screen onall petsin order to provide the safest and best care possible. This screen evaluates numerous organ systems to help ensure that no underlying health problems exist prior to anesthesia and surgery.

COAGULATION (CLOTTING TIME) SCREEN

In addition, we also recommend a coagulation (clotting time) screen for your pet. Hemophilia and clotting deficiencies are relatively uncommon but can be fatal if not detected prior to surgery. Cost: $29.00

 I WOULD like the above Coagulation Screen performed on my pet.

 I DECLINE the above Coagulation Screen and accept full responsibility. Please initial: ______

PAYMENT METHOD

How do you intend to pay for services today? Please circle one: Cash Check Visa Mastercard Discover

Thank you for trusting us to perform your pet’s surgery. We use the safest, most up-to-date anesthetics and monitoring devices available, but this does not absolve all risk. All anesthetics carry risks ranging from mild post-op nausea to the remote possibility of loss of the patient. While these occurrences are rare, they do happen occasionally even though protective measures are taken. In addition, no guarantee nor warranty can ethically or professionally be made regarding the result or cure of the pet.

I authorize and direct the veterinarians of the Dupont Veterinary Clinic, Inc to perform the procedures and/or administer anesthetics as deemed advisable for my pet. I certify that I have read and fully understand this authorization for treatment and have had all questions answered to my satisfaction regarding risks, options for treatment and possible outcomes. I hereby release Dupont Veterinary Clinic and the veterinarians employed therein from liability. I agree to pay, in full, for services rendered, including those deemed necessary for medical or surgical complications or unforeseen circumstances.

I understand that all charges for services from this hospital are due at the time of discharge and must be paid

before my pet can be released.

______

Signature of Owner or Responsible Agent Date