Name *

First Name

Last Name

Date

MM

DD

YYYY

Date of Pick up

MM

DD

YYYY

Owner

First Name

Last Name

Agree

Disagree

Please perform whatever services the doctor deems necessary for the best care of my pet until someone can be reached. This includes only non elective treatments and necessary diagnostics.

DO NOT administer any medical treatment until specific authorization is given.

I have read and understand this agreement. I fully intend to pick up my pet(s) on the above specified date. If circumstances change, I will notify the veterinarian of a new pick up date.

Owner

First Name

Last Name

Date

MM

DD

YYYY

I authorize the above named Veterinarian and/or her staff to perform the treatments/ procedures listed below. I have been informed of the expected benefits and potential risks involved. I am the owner or authorized agent and have the authority to execute consent.

In-House Presurgical Blood work (Cost: $45):

Yes

No

Microchip placement:

Yes

No

Update Vaccinations (If necessary):

Yes

No

De-worm (recommended every 3-12 months depending on risk):

Yes

No

Is your pet currently on any medications?:

Yes

No

IV Pre placement/ Catheterization:

Accept

Decline

Cost:

$42.00 IV Catheter

$62.00 IV Catheter with fluids

Mass Removal: Would you like the mass sent off for Histopathology?

Yes

No

If so, please choose:

Montana State Lab $90.00 (7-10 Days for results)

Idexx Lab $178.18 (3-5 Days for results)

I understand that there are certain risks to anesthesia that could involve bodily injury or death. These risks are present with any procedure that requires general anesthesia or intravenous anesthesia. I consent to the use of anesthetics. I also understand that unforeseen conditions may require an extension of a planned procedure or operation. I hereby authorize the performance of such procedures or operations as necessary and advisable in the professional judgment of the veterinarian. I have read and understood this consent form. I realize that results can not be guaranteed. I consent to the proposed treatment/ procedure.

Owner *

First Name

Last Name

Date *

MM

DD

YYYY

How is your pets appetite?

Increased

Normal

Decreased

Refuses food/treats

How is your pets water consumption?

Increased

Normal

Decreased

Have you noticed any vomit?

No

Yes

Have you noticed any diarrhea?

No

Yes

How is your pets energy level?

Normal

Slightly Decreased

Lethargic

Is your pet on any medicines/supplements?

No

Yes

Date

MM

DD

YYYY

Date of Pick up

MM

DD

YYYY

Owner

First Name

Last Name

Bath

Yes

No

Medication

Yes

No

Spayed/Neutered

Yes

No

Agree

Disagree

Please perform whatever services the doctor deems necessary for the best care of my pet until someone can be reached. This includes only non elective treatments and necessary diagnostics.

DO NOT administer any medical treatment until specific authorization is given.

Playtime

Yes

No

Individual Playtime Canine (Additional fee is $10.70 per session/day)

Yes

No

Social Playtime Canine (Additional fee is $10.70 per session/day)

Yes

No

All dogs are screened for aggressive behavior, but fights can and will still occur. I understand that the staff will do all they can to prevent fighting. I also understand that it is possible for a dog to sustain wounds from playing rough. I understand that I will be held financially responsible for any medical bills incurred as a result of my dog participating in Social Play, including medical bills incurred as a result of my dog injuring another.

I have read and understand this agreement. I fully intend to pick up my pet(s) on the above specified date. If circumstances change, I will notify the veterinarian of a new pick up date.

Date:

MM

DD

YYYY

Name

First Name

Last Name

Spouse/Other

First Name

Last Name

Birthdate:

MM

DD

YYYY

Dog

Cat

Other

Male

Female

Neutered/Spayed?

Yes

No