CANINE
Bountiful Animal Pre-Anesthetic / Surgical / Hospitalization Consent Form
Please Read Carefully, Initial, and Sign
Client: _________________________________
Patient: ________________________________
Age: ____________________
Emergency/Alternate phone numbers: ________________________________________________________________________
Procedure(s):_____________________________________________________________________________________________
_____ I certify that I am the owner/agent of the above animal and do hereby give consent to the Bountiful Animal Hospital to provide such
treatment as deemed essential by the attending veterinarian. This may include such things as hospitalization, surgery, anesthesia, or other
such treatments.
_____ Our greatest concern is the comfort and well-being of your dog, especially during treatment. I understand that although the anesthetic
and surgery protocols used today are relatively safe, there is always a potential risk associated with their use. I agree not to hold the Bountiful
Animal Hospital veterinarians and staff liable for any untoward events or complications that may occur in the absence of gross negligence.
In the event that my animal arrests while hospitalized at Bountiful Animal Hospital I authorize the following CPR code:
_____ Normal CPR: involving chest compressions, oxygen therapy and medications such as epinephrine, atropine, etc.
_____ DNR: No resuscitation
Certain medical conditions that may not be evident on a routine physical exam can potentially complicate the risk to your dog when put under
anesthesia or through surgery. Bountiful Animal Hospital offers and recommends a pre-anesthetic blood profile be performed in order to
screen the major organ systems, ie. liver, kidneys, glucose, for such problems. Blood work is required for animals 7 years and over.
Accept Blood Work Options: 10 Panel $73 ________ 15 Panel $88________ CBC $71 ________
Decline Blood Work ________
_____ I understand that because my dog will be undergoing surgery, medications for pain and inflammation will be administered.
We recommend all dogs be tested for Heartworm disease before starting the preventative. Once on the preventative medication testing is
recommended every 2 years.
Accept Heartworm test $56________
Decline Heartworm test ________
Laser Therapy: Application of the laser after your pet has undergone surgery greatly enhances tissue healing and reduces pain and
inflammation. $20 for dogs under 40lbs $25 for dogs 40lbs and over.
Accept Laser Therapy_____
Decline Laser Therapy____
Vaccinations: An important aspect in keeping your dog healthy is administering annual vaccinations. We recommend clients keep their dog
current on all necessary vaccinations.
** Administer vaccinations at this time: DHPPL w/ Intranasal Bordetella $39 ________
Influenza $30 or $54 ________
RABIES $20 or $32 ________
_____ Decline vaccinations at this time and understand the risks involved.
_____ Pet is current on vaccinations at this time.
Microchips are extremely useful in identifying and returning your pet to you in the event you become separated. To ease the discomfort of
having the chip placed, this may be done while your animal is under anesthesia. The price includes the microchip, one time activation and
enrollment.
Accept Microchip $50.95 ________
Decline Microchip _______
I further realize that I am responsible for payment in full at the time the animal is discharged. If I neglect to pick up the animal within five days
you may assume that the pet is abandoned. At this time, Bountiful Animal Hospital will assume ownership of the animal and do what is
deemed best and necessary. Abandonment does not release me of my obligation for the bill. I further agree that in the case of non-payment,
a finance charge of 1.5% per month will be charged and any collection fees or attorney fees will be my responsibility.
_____________________________________
________________
Owner/Agent Signature
Date
**Forms of Payment Accepted: Cash, Visa, Mastercard, Discover, Care Credit**
**No checks accepted**