North Shore Animal Hospital
One Neptune Blvd
Lynn, MA 01902
(781)596-0510
Date: _________________
Your Full Name: ____________________
Pet’s Name:_________________
Address: __________________________
Sex: _______________________
City, State, Zip: _____________________
DOB: _______________________
Phone Number: ____________________
Breed/Color: __________________
PLEASE VERIFY THAT THE ABOVE INFORMATION IS CORRECT.
__________(pet’s name) is being admitted to our hospital to undergo a surgical
and/or dental procedure requiring anesthesia. Anesthetic procedures involve an
inherent risk and results cannot be guaranteed. We have minimized the risk of
anesthesia by using modern and safe anesthetic agents. In addition, all pets are
given a physical examination prior to the scheduled procedure. An
appropriate injectable pain relief medication will be administered
immediately following surgery. This medication will control pain and keep
your pet comfortable here and at home. Your pet will have a faster recovery
time and be less likely to have surgical complications.
There will be additional charges for pain relievers and for animals that are
in heat or pregnant or excessively over weight and are undergoing a
spay/neuter surgery. The charges for pain relievers will not exceed $45.
Please discuss quotes with the receptionist. We recommend, to further insure
the safety of your pet, a preoperative blood screening. This screening is similar
to those used in human hospitals and is available to assess your pet's risk for
certain complications. The blood is analyzed in our laboratory prior to surgery.
Your pet's preoperative blood screen may include tests to evaluate liver and
kidney function, blood sugar level, or for other blood abnormalities. Sick
animals or animals over seven years of age will have blood tests
performed. The receptionist can explain various fees ($55.00 to $185.00).
Pets found to have fleas or evidence of fleas (flea dirt) will be treated with
an appropriate flea product and your account will be charged accordingly.
YES
--I have read the above and agree to this lab work for my pet. If any
significant abnormalities are found, contact me at the number below.
NO
--I have read the above and elect not to have the lab work
performed. By declining required blood tests, I realize that the procedure may
be cancelled. I agree to hold North Shore Animal
Hospital, Inc. harmless in the event of anesthetic, surgical or medical
complications that might have been detected had these tests been performed.
Please be aware that there is not a twenty four hour on site staff member
available at the hospital.
All fees must be paid in full at the time services are performed
or upon discharge from the hospital. Any exception to this policy must be
authorized prior to the performance of any service. We accept cash, only checks
approved via Telecheck (Must have ID), Master Card, Visa, American Express,
Care Credit and Discover for your convenience.
I am the owner (or owner's agent) of (Pet’s Name)____________________________ .
I understand that I am authorizing performance of the following procedure(s):
PROCEDURE: (LISTALLPROCEDURES)__________________________________________
All animals admitted must be current on their core vaccinations. If we have
no record of your pet's vaccines, please provide vaccine certificates.
Additionally, we highly recommend that dogs be vaccinated for Lyme disease,
tested for heartworm and Lyme disease and maintained on heartworm
preventative throughout the year. We recommend that all cats be tested for
leukemia and FIV and received leukemia vaccine if at risk for exposure. We
recommend that all dogs and cats be tested for internal parasites, use flea/tick
preventatives and be microchipped.
While your pet is under anesthesia, would you like any of the following
recommended services performed? Be advised that there will be additional fees
related to your selections below.
Feline Leukemia/FIV Test $58
Vaccinations Ask for Quote $
Treat for Fleas Ask for Quote $
Express Anal Sacs $35
Implant Microchip & Register $54
Nail Trim $4
Ear Cleaning $6
Heartworm (4DX) Test $61
(Registration Only $25 )
Other, please specify
________________________________________________________
Please discuss fees and any questions and concerns with your receptionist.
PROCEDURE AUTHORIZATION for (Pets Name)______________ belonging to
(Owner) __________________ :
I have had the reasons for surgery or anesthesia explained to me and I am
satisfied with the plan of management for __________ . I have also had the likely
fees explained to me and accept responsibility for payment of these fees at the
time of _________________'s discharge.
Please confirm the address above as well as the phone numbers and email
address below by completing the appropriate boxes:
Home Phone: __________________ Cell Phone: ____________________________
Alternate Phone Number:_______________________
Email Address: _______________________________
Signed: ______________________________________________________
Print Name of Person Authorizing Procdure(s_________________________
Owner or Agent, please indicate who is authorizing.
North Shore Animal Hospital Witness: ____________________________
Date_____________________________
PLEASE BE SURE TO LEAVE A PHONE NUMBER WHERE WE CAN REACH YOU
THIS MORNING AND THROUGHOUT THE DAY.