| AUTHORIZATION TO PERFORM SURGICAL PROCEDURE |
| Owner's Name: | |
| Patient: | |
| Procedure: | |
| Date: | |
| I hereby authorize the above procedure, 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 the results or cure. I understand that I assume financial responsibility for all services rendered and that payment is due when services are completed. |
| Owner or agent of Owner: | |
| Date: | |
| Current Medications: | |
| Because no surgery or anesthetie procedure, however small, is without some risk, we routinely perform a pre-surgical blood test to help determine your pet's internal health. |
| These tests check for abnormalities in your pers ability to process the anesthetic, fight infection, carry oxygen to the tissues and prevent excessive bleeding. If the results are normal, they give us a "baseline" for your pet that we can use to measure apainst test results during an illness.
Remember, your pet ages about 7 years for every "human" year, so changes can occur more rapidly in pets than in people. | |
Our staff will recommend tests based on your pet's age, physical condition, and the procedure to be performed. | The results will be available to us before surgery and, should there be any indication that an abnormality exists, the doctor will contact you before proceeding. | | Option to decline Blood Work: |
| I understand the risks to my pet and choose not to have the pre-surgical blood work performed. I take full responsibility and hold harmless Kalona Veterinary Clinic, PC and its staff and doctors for amy result or condition that may have been determined by the recommended blood work. |
| Owner or agent of Owner | |
| Date: | |
| All animals admitted to the hospital for surgery that are found to be infested with fleas will be treated with a flea product and the owner will be billed accordingly. |
| Phone number where you can be reached today: | |
