Authorization for Anesthesia and/or Surgery
Client Name: _______________________________
Today's Date: __________________
Pet's Name: _______________________ Species (K9/Feline): _______ Breed: _____________
Age or Date of Birth: ____________ Sex: ___ Female ___ Male ___ Spayed Female ___ Neutered Male
Anesthetic and surgical procedures(s) to be performed: _______________________________________________
I, the undersigned owner or agent of the owner of the pet identified above, certify that I am eighteen years of age or over
and authorize the veterinarian(s) at Larchmont Animal Hospital to perform the above procedures(s). I have provided all
contact numbers where I or my agent can be reached today.
I understand that some risks always exist with anesthesia and/or surgery, including complications, injury or even
death, and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before
the procedure(s) is/are initiated. My signature on this form indicates that any questions I have regarding my pet's treatment
options, the procedure itself, recovery, complications and risks, at-home aftercare and cost have been answered to my
satisfaction.
While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand
that no guarantee or warranty has been made regarding the results that may be achieved. Should unexpected life-saving
emergency care be required, the hospital staff has my permission to provide such treatment until I can be contacted. I
agree to pay for such care should it become necessary.
Pre-anesthetic blood testing
Pre-anesthetic blood testing is required for all animals over the age of 3 years and is available for any animal under 3
years upon request. This testing allows the veterinarian to better assess the overall health of your animal and assess his/her
surgical risk.
For animals over 3 years of age only:
____ If lab work has not been performed in the past two weeks, I understand that it will
be performed today. (cost for animals under 6 years, $107, over 6 years, $129)
For animals under 3 years of age only:
____ I request pre-anesthetic testing for my pet (cost: $107)
____ I decline pre-anesthetic testing for my pet
Vaccinations and Routine Care
All surgical patients must be current on vaccinations and fecal examination, and dogs must be current on heartworm
prevention or testing prior to their procedure. I understand that is my responsibility to provide documentation for any
vaccines/treatment performed at another facility, and understand that if my pet is not current, he/she will be
vaccinated/tested prior to the procedure and the costs will be added to my bill.
Microchipping
A microchip is a permanent form of identification which can be implanted under your pet's skin. When a lost pet is found,
a shelter, hospital or rescue group scans the pet, contacts the HomeAgain database and matches the microchip id number
with the owner's information.
____ Microchip my pet (implantation cost $65;
HomeAgain registration fee of $16.99 not included)
____ Do not microchip my pet
____ My pet is already microchipped
Phone number(s) at which owner or agent can be reached today and/or tomorrow.
___________________________________________________________________________________________
I have read and fully understand the terms and conditions set forth above.
_________________________________________________
Signature of Owner or Agent
_________________________
Date