Hospitalization/Surgical Release Pet Name* Owner Name* Owner’s Primary Contact Number* Please select...*HomeCellWorkAlternate Contact Name Alternate Contact # Please select...HomeCellWorkMy pet will have no food starting at 10pm the day before the procedure.* Type your initials here to indicate you understand the above instructions.I am the owner or agent for the owner, of the above described animal and have the authority to execute this consent. I hereby consent to and authorize the performance of the hospitalization/surgical procedure.Requested treatment/procedure desired:*I understand that during the performance of the foregoing procedure(s), unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure(s) or a different procedure(s) than those set forth. I understand that an effort will be made to contact me at the telephone numbers provided in the event another procedure(s) is performed. If your pet's procedure is not having anesthesia please complete this as a pre-caution due to hospitalization. I realize that any procedure involving general anesthesia carries a risk, although very small, of death.In such case, I authorize the following measure to be taken* No resuscitation External resuscitation IF FLEAS OR TICKS ARE FOUND ON YOUR PET AT THE TIME OF ENTRY, YOUR PET WILL BE TREATED AND THE MEDICATION WILL BE REFLECTED ON YOUR INVOICE UPON CHECK-OUT.Acknowledgement of flea/tick statement* YES - I UNDERSTAND If your pet does not have a microchip and is being sedated this is an ideal time to do this procedure. Please refer to the Home Again Microchip online form for details. I hereby authorize the veterinarian to examine, prescribe for, and/or treat the above-described pet. I assume responsibility for all charges incurred in the care of this animal. I also understand that all charges must be paid at the time services are rendered and that a deposit may be required for surgical treatment or hospitalization. Please type your Digital Signature:* Date* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
