WAUPACA SMALL ANIMAL HOSPITAL, LLC
780 Bowling Lane Waupaca, WI 54981
(715) 258-3343
Dr. John Meshigaud & Dr. John Klessig & Dr. Shari Hanneman
Owner: ____________________________________ Patient(s): _____________________________________
Species: _________ Breed: ____________________________________________ Age: _________________
Colors & Markings: ______________________________________________________ Sex: M MN or F FS
Current Medications: _______________________________________________________________________________
Daytime Contact Number: ___________________________________________________________________
Method of Payment: (__) Cash, (__) Check, (__) VISA, (__) MasterCard, (__) Discover or (__) Care Credit
Insurance Carrier if any: _____________________________________________________________________
Procedure Release
As the owner of the described animal(s), I hereby authorize the agents of the Waupaca Small Animal Hospital
to perform the following procedure(s) or treatment(s) for my animal(s):
____________________________________________________________________________________________
The nature and purpose of these procedure(s) or treatment(s), the associated major risks and available alternative
treatments have been explained to me. I acknowledge that no guarantee has been made as to the results that may
be obtained. I understand that complications may arise which cannot be predicted. I understand that I will be
financially responsible for any veterinary medical care necessitated by complications.
If unforeseen conditions arise which, in the judgment of the attending veterinarian, call for procedures or treatments
other than those now being authorized, I authorize such procedures or treatments if reasonable efforts to contact me
for further consent are unsuccessful.
Anesthesia Release
The purpose of anesthesia (general, sedation, and tranquilization) is to suppress the central nervous system in order
to decrease anxiety, relax muscles and/or eliminate the perception of pain.
It is important to recognize that anesthesia has an inherent risk associated with its use. Anesthetic
complications and fatalities are uncommon, especially in young and healthy animals; however, complications
cannot always be predicted or prevented.
I hereby authorize the agents of the Waupaca Small Animal Hospital, to administer anesthesia to my pet.
I realize that the Doctors recommend pre-anesthetic blood testing for all procedures requiring the use of anesthesia.
I also realize that unforeseen complications may arise during or after anesthesia, and I authorize the veterinarian in
charge to provide supportive care as needed. I understand that I will be financially responsible for any and all
potential complications.
I acknowledge that I have carefully reviewed the information above. Furthermore, I understand that I should
not sign this release form if I have any unanswered questions or concerns.
Signature _____________________________________________________ Date __________________________
Please see reverse side 
Please read the following:
Preanesthetic Blood Screen
Each surgical or anesthetic procedure has some risk associated with it, as noted previously. Therefore, a blood test
is recommended before the anesthesia or surgery is performed. A portion of the anesthetic agent is removed from
the body by the liver and/or kidneys, so it is very important to identify any potential problems with these organs
before administering anesthesia. The preanesthetic test will evaluate the liver, kidneys, proteins, and glucose for
your pet. If abnormalities are detected; the appropriate steps will be taken to ensure the safety of your pet. If the test
is normal for your pet, the results will serve as a baseline for future comparison.
You may elect to have this test done by marking the appropriate response below. Our laboratory is fully equipped
and staffed to perform these blood tests. Results will be immediately available before your pet’s anesthesia or
surgery is performed. If there is any indication of an abnormality, we will either contact you before proceeding or
take the steps necessary to ensure the safe care of your pet.
Fee for blood screen: $ 57.20
*Please indicate your response below:
(_) YES, I request the preanesthetic blood screen for my pet.
(_) NO, I decline the preanesthetic blood screen for my pet.
Permission to Provide Appropriate Pain Relief
Pets cannot tell us when they hurt, so it can be difficult to know when they are in pain. Since the perception of pain
is similar for humans and pets, we assume any condition or injury capable of causing pain in humans is also
capable of causing pain in pets. Pain is more than an unpleasant sensation. If left untreated, it can lead to
suffering and harmful physical effects, and actually interfere with the healing process.
Our practice understands the importance of pain management and offers effective methods to meet your pets
specific needs. Although pain medication is routinely given for each procedure, this medication has limited
effectiveness postoperatively. We will provide additional pain relief medication for your pet if you request. Your pet
would receive an additional injection of pain medication after the procedure, and oral medications for the following
couple of days.
Fee for additional medication (injection and oral medication): $ 28.00 or (Injection only): $21.00
*Please indicate your response below:
(_) YES, I request additional pain medication for my pet. (injection and oral medication) Or
(_) Yes, I request additional pain medication (Injection only)
(_) NO, I decline additional pain medication for my pet.
Signature _________________________________________________________Date _____________________________
Waupaca Small Animal Hospital, LLC 780 Bowling Lane Waupaca
(715)258-3343
YOUR PET IS SCHEDULED FOR AN ADMISSIONS APPOINTMENT
ON: ______________________________________ AT:____________________am / pm
PLEASE BRING THIS COMPLETED FORM FOR YOUR APPOINTMENT
A 24-HOUR CANCELLATION NOTICE IS APPRECIATED IF YOU ARE UNABLE TO KEEP THIS APPOINTMENT
*PLEASE, DO NOT OFFER ANY FOOD AFTER MIDNIGHT THE NIGHT BEFORE APPOINTMENT. OFFERING WATER IS OK.
THANK YOU!
Laser Surgery Consent Form For Declaws
Waupaca Small Animal Hospital
780 Bowling Lane
715-258-3343
Owner: ______________________________________ Pet: ______________________________
As part of our commitment to quality care, we are pleased to offer laser surgery as an
option for safe, comfortable treatment for your pet. We feel that laser surgery offers
several advantages for your pet. Among those advantages are:
1.
LESS PAIN - the laser seals the nerve endings as it “cuts”, which greatly helps reduce the
post-operative pain . This is a major advantage for declaw surgeries in cats.
2.
LESS BLEEDING - the laser seals small blood vessels during surgery, greatly reducing the
blood loss. This is a great advantage during more complex surgeries
such as spays and mass removals.
3.
LESS SWELLING - the laser seals lymphatic vessels to prevent leakage, and does
not crush or tear tissues because there is no physical contact
with the tissue.
4.
PRECISION - the laser delivers an extremely fine beam of light which vaporizes the
cells, allowing precise removal of very small amounts of tissue.
Your pet will be treated with a carbon dioxide laser, which produces an invisible beam
of light that can remove a precise layer of tissue at one time. All this can reduce your
pet's post-operative recovery time, leading to a quicker return to normal activities.
________________________________________
Signature of owner or agent
_____________________
Date
If you have any questions, please call our office at 715-258-3343
Please bring this completed form for your appointment.
Thank you!
Laser Surgery Consent Form
Waupaca Small Animal Hospital
780 Bowling Lane
715-258-3343
Owner: ________________________________ Pet: _____________________________
As part of our commitment to quality care, we are pleased to offer laser surgery as an
option for safe, comfortable treatment for your pet. We feel that laser surgery offers
several advantages for your pet. Among those advantages are:
1. LESS PAIN- the laser seals the nerve endings as it “cuts”, which greatly helps reduce the
post-operative pain. This is a major advantage for declaw surgeries in cats.
2. LESS BLEEDING- the laser seals small blood vessels during surgery, greatly
reducing the blood loss. This is a great advantage during more
complex surgeries such as spays and mass removals.
3. LESS SWELLING- the laser seals lymphatic vessels to prevent leakage, and does
not crush or tear tissues because there is no physical contact
with the tissue.
4. PRECISION- the laser delivers an extremely fine beam of light which vaporizes the
cells, allowing precise removal of very small amounts of tissue.
Your pet will be treated with a carbon dioxide laser, which produces an invisible beam
of light that can remove a precise layer of tissue at one time. All this can reduce your
pet’s post-operative recovery time, leading to a quicker return to normal activities.
I understand that laser surgery is an option* and I have been advised of the advantages
the procedure will offer my pet. *Please indicate your response below:
_____ YES, I understand the benefits and I want my pet to have
laser surgery. Additional cost is $ 62.80
_____ NO, I decline laser surgery for my pet.
*The use of the laser in complex surgical procedures may be required at
the doctor’s discretion.
_______________________________________
Signature of owner or agent
_______________________
Date
If you have any questions, please call our office at 715-258-3343
Please bring this completed form for your appointment. Thank You.