Cochrane Animal Hospital
AUTHORIZATION FOR SERVICES
OWNER_____________________________________________ PET NAME(S)___________________________
PHONE NUMBER(S) WE CAN CALL TODAY____________________________________________________
I hereby authorize performance of the following surgical/medical care procedure(s):
________________________________________________________________________________________________________,
and such additional procedures as are considered therapeutically and/or diagnostically necessary on the basis of findings
during the course of said evaluation. I also consent to the administration of such anesthetics as are necessary.

Cochrane Animal Hospital Staff will practice accepted veterinary medical standards while administering anesthesia and
performing surgery. I understand there are certain risks inherent with anesthesia and surgery, and that circumstances can
arise beyond such standards. The nature of such service has been described to me to my satisfaction and I realize that no
guarantee or warranty can ethically or professionally be made regarding results or cure. I therefore agree that Cochrane
Animal Hospital, its veterinarians, and paramedical personnel will not be held responsible in the event of this animal’s death,
injury, or escape. In addition, I agree to indemnify, defend, and hold harmless Cochrane Animal Hospital in case of such an
event. __________ (Initial)

I understand that it is recommended that my veterinarian check this animal prior to surgery for any health problems that
could complicate anesthesia or surgery. To my knowledge, this animal does not currently have any health problems.
__________ (Initial)

In the event that this animal has problems at home that may be related to this surgery, I will attempt to contact the Cochrane
Animal Hospital. Post-operative re-checks are subject to a Re-check Examination fee AND payment for each medication
that may be prescribed. If such problems occur when the clinic is closed, I will get veterinary attention for the problem in a
timely manner and I acknowledge that this care will be obtained at my own expense. __________ (Initial)

Should the Cochrane Animal Hospital staff feel that staff or this animal’s health and/or safety is at risk due to this animal’s
behavior while this animal is at the Cochrane Animal Hospital, the staff reserves the right to refuse to perform the requested
procedure and will contact the owner to pick up the animal. __________ (Initial)

ADDITIONAL FEES: I understand that I am responsible for the estimated surgical fee and all additional costs connected
with medical procedures performed upon this animal and will pay said costs prior to release of the animal to my care.
Additional costs include, but are not limited to: in-heat, pregnancy, lactation, obese, ovarian cysts, pyometra (infected uterus),
cryptorchid (only one testicle descended), dental extractions, E-collars, and required vaccinations. Should the animal not be
picked up on the day of surgery, I will be responsible for a boarding fee. If I fail to reclaim the animal within fourteen (14)
days of receiving written notice to do so, I waive my claim to said animal. Furthermore, I authorize the Cochrane Animal
Hospital, at its sole discretion to dispose of the animal appropriately. I understand that failure to reclaim the animal does NOT
relieve me of the obligation to pay costs of services rendered. __________ (Initial)

REQUIRED VACCINATIONS: Vaccinations required for dogs are DALP-PV (distemper/parvo), Bordatella (kennel cough),
and Rabies. Vaccinations required for cats are FVR-CP (distemper), FELV (leukemia), and Rabies. __________ (Initial)

POST-OPERATIVE PAIN MANAGEMENT: The clinic offers an option for pain management after surgery. The doctor can
give a pre-op injection and send your pet home with post-op oral medication to reduce pain and expedite the healing process.
The clinic strongly recommends the pain management, but it is not required. There is a $35 fee for felines and a $35-$55 fee
for canines, depending on weight.
PLEASE INITIAL YOUR CHOICE BELOW.
________ YES ($35 - Cat or $35, $45 or $55 – Dog)

_________ NO, I decline pain management
DISCHARGE INSTRUCTIONS: As with any surgical procedure, it is important to provide proper post-operative care and
close monitoring to prevent any complications. Once the patient has been discharged from this facility, it is the owner’s
responsibility to follow the discharge instructions and provide accurate post-operative care at home. I acknowledge that I
have received a hard copy of the Discharge Instructions and that our staff has explained these instructions to the owner’s
satisfaction. __________ (Initial)
As the guardian/owner or agent for said animal, I authorize Cochrane Animal Hospital to prescribe medication, treat
or perform surgery on this animal as needed.
SIGNATURE X____________________________________________________________ DATE__________________________