Little Miami Veterinary Service
Date__________________
Owner’s Name___________________ Pet's Name______________
Pet's Species_____________
AUTHORIZATION FOR MEDICAL AND/OR SURGICAL TREATMENT
I, the undersigned owner or agent of the owner, hereby authorize the
professional staff of this clinic to perform the following procedure(s) or
operation(s):
I understand that during the performance of these procedures, unforeseen
conditions may be revealed that necessitate an extension of the foregoing
procedure(s) or operation(s) or different procedures or operation(s) than
those set forth above. Therefore, I hereby consent to and authorize the
performance of such procedures or operations as are necessary and
desirable in the exercise of the veterinarian’s professional judgment.
I also authorize the use of appropriate anesthetics and other medications,
including analgesics (for pain control), and I understand that hospital
support personnel will be employed as deemed necessary by the
veterinarian.
I have been advised as to the nature of the procedure(s) or operation(s)
and the risks involved. I realize that results cannot be guaranteed.
I assume full financial responsibility for all charges incurred to the patient
and consent to the release of medical information.
I have read and understand this authorization and consent.
X___________________________
Signature of owner/responsible agent
Daytime Phone____________
Cell Phone _______________
Any animal undergoing a procedure requiring anesthesia must have PreAnesthetic Bloodwork completed, at the cost of $41.00, before the
procedure can be performed. I have been explained the benefits and risks
of the blood work and anesthesia.______
All animals who have never been examined at this clinic must be
examined by our Drs. at the cost of $37.00 before any surgical procedures
can be performed._______
Any dog that has not been on regular Heartworm prevention and/or has
not been tested for heartworm within the last year, must be tested for
heartworm at the cost of $31.00 before any anesthetic procedure can
performed.______
An Elizabethan (E) collar is required for all male dogs undergoing surgery
to prevent complications from chewing at the surgical site.______
For any cat undergoing an anesthetic procedure, an ECG is required at
the cost of $14.00. This test is optional for dogs undergoing anesthetic
procedures, but highly recommended.______
The following is a list of procedures that you may want to have done while
your pet is under anesthesia. Please “X” the ones that you authorize us to
do:
Toenail trim (no charge)
Check ears (no charge)
_____ Pain medication to go home, if needed (cost varies)
Feline Leukemia/FIV test (cats only) $42.00
Clean ears (if needed) $12.00 per ear
Flush ears (if needed) $15.00 per ear
Check anal glands & express if needed $20.00
Hand scrape mild tarter on teeth $23.00
Flea treatment (must treat if fleas present) $ according to weight
Microchip $60.00
_____ Other_________________________________________________