Consent Form
Patient Name:
Contact / Emergency #’s: Home: _____________
Cell: _____________
Work: _____________
E-mail for ePetHealth online record access: ____________________________________________
Medical / Surgical / Dental Care
□ Surgery / Dental per estimate
□ Annuals or Well Visit Vaccines or
testing per estimate
□ Sick Visit: Please describe concerns
□ Microchip my pet
*save $15 w/ any package or surgery
□ Medication Refill(s) Needed:
□ Revolution:
1
6+1
12+2
□ Heartgard Plus:
1
6
12
□ Trifexis:
1
6
12
□ Other Medications: Please List
Boarding
Bathing
□ Dry food included at no additional
charge: Royal Canin GI Low Fat for
dogs or Science Diet Feline Maint.
□ Bath / Nails / Anal Glands if needed
□ Grooming
Please describe grooming requested:
□ Feed my pet’s Own Food:
____________________________
Amount / Meal _____cups _____cans
# Meals / Day? 1 2 3
Pick up Time Preferred IF available:
Playtime 15 min/play session:
□1X/day □2X/day □3X/day □4X/day
$5
$9
$15
$20
(weekends max out at 2X/day)
Medications to give listed below
at $4/day of boarding:
1. ______________________
1. ______________________
2. ______________________
2. ______________________
□ By noon
□ 12-2
□ 2-4
□ After 4
*****NOTE*****
Pick up time is between 4 and 7
unless called earlier or prior
arrangements have been made
between you and our groomer. We
will try to honor requests above.
3. ______________________
1. I understand that conditions may arise during the above procedures or operations whereby a different procedure or
operation may be necessary to be performed. I authorize the attending Doctor to exercise his professional judgment in
performing such procedures(s) or operation(s) using appropriate measures to communicate with me if possible.
2. I have been advised as to the nature of the procedure(s) or operation(s) and the risks involved. I understand
complications including, but not limited to infection, cardiac arrest, and death could result. I acknowledge that no
guarantee has been made as to the result or cure.
3. I understand that any patients who have contagious parasites will be treated at my expense.
4. I accept all financial responsibility for the treatment of the above-named animal, and I understand that payment in full
is due upon release of this animal from the hospital or when service is otherwise terminated.
5. I understand that my pet MUST be current on vaccinations (including DHPP, Bordetella, Flu, Rabies, Leukemia, FVRCP)
to be in our hospital. Titers will be allowed to be used in lieu of some vaccinations and are considered good for 3 years. If
not current, I understand that my pet will be given any vaccines that the doctor determines are required and safe to give
and I will be financially responsible at the time of discharge. NOTE: If your cat lives 100% indoors and has had a
negative leukemia test since becoming an indoor cat, the requirement for the leukemia vaccine will be waived.
For anesthetic procedures only:
PRE-ANESTHETIC BLOOD TESTING and ELECTROCARDIOGRAM: Like you, our greatest concern is for the well being
of your pet. Before we anesthetize your pet, we will perform a physical examination. Many conditions, including disorders
of the liver, kidney, blood, and heart may not be detected without blood testing or performing an EKG. We require current
baseline blood work w/ in a month or so of anesthesia on all well pets and on the day of anesthesia for sick pets or pets on
chronic medications. Pre-Anesthetic EKGs will also be done on all patients over 7 and on any pet with a heart murmur or
with a suspected arrhythmia found on any pre-op exam or with a major illness. We recommend EKGs on ALL patients
regardless of age. We are trying to be as safe as we possibly can with our patients. We know that while outcomes can
never be guaranteed, we may help detect and help prevent avoidable medical compromise of your pets if we can identify
risk factors BEFORE a complication occurs. ***The only exceptions to the above policy are pets who are not safe to handle
for the testing or who cannot wait for testing to be put under anesthesia.
My Pet is UNDER 7 yrs. & I WANT the EKG already included in my estimate
My Pet is UNDER 7 yrs. and does NOT have a heart murmur or arrhythmia & I DECLINE the EKG today
SIGNATURE: ______________________________________
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