Client Name* First Last Primary Phone*Secondary PhoneEmail Address* Pet's Name* Procedures Elected* Dental Cleaning Growth Removal Please select from the following options for further diagnostics on the growths to be removed.* Histopathology In-clinic cytology Decline further diagnostics Additional Surgical Procedures* Yes No Additional Surgical Procedure:*Procedural Information and Hospital Policy Pre-anesthetic Blood Testing:Pre-surgical blood tests along with physical exams are required prior to all dental procedures as they will enable us to assess and minimize the risk of anesthesia to your pet by creating a protocol tapered to your pet’s specific needs.Blood Work Completed?* Yes No Date of Completion* MM slash DD slash YYYY Pre-Anesthetic Testing Heartworm with Tick Disease ($42) Heartworm with Feline Leukemia and FIV ($57.50) Complete Blood Cell Count ($30) Blood Chemistry Panel ($85) Decline all diagnostic testing Monitoring:To minimize anesthetic risk, we monitor your pet’s heart rate, blood pressure, respiratory rate, temperature, and oxygenation throughout the procedure. Catheterization:For sterility, hair will be shaved over a vein on the leg so that an intravenous (IV) catheter can be placed. Blood pressure may lower during anesthetic procedures and fluid therapy aids in supporting your pet’s internal organ systems. It, also, allows immediate access to the vascular system in case of an emergency. Pain Management:The doctors will administer pain medications according to your pet’s needs before, during, and after the procedure. Some pain medications can incur an additional fee, ranging from $22-65.00 Antibiotics:The doctors may administer antibiotics according to your pet’s needs. These medications may incur an additional fee, ranging from $22-80.00. General Patient History and InformationDid your pet eat this morning?* Yes No How Much Did They Eat?When did they eat?*Is your pet current on vaccinations (choose dog or cat)?* Dog Cat Rabies?* Yes No Please note if your pet is not current on their Rabies vaccination, they will receive a vaccine today.DHPP?* Yes No Bordetella?* Yes No Rabies?* Yes No Please note if your pet is not current on their Rabies vaccination, they will receive a vaccine today.CVRP (Upper Respiratory combo)?* Yes No Leukemia?* Yes No Has your pet experienced any vomiting or diarrhea within the past two weeks?* Yes No Vomiting, Diarrhea, or Both?* Vomiting Diarrhea Both When did you notice it?*Has it Resolved?* Yes No Has your pet experienced any coughing or sneezing within the past two weeks?* Yes No Coughing, Sneezing, or Both?* Coughing Sneezing Both When did you notice it?*Has it Resolved?* Yes No Does your pet have a history of seizures?* Yes No When was the last seizure?* Is your pet currently on anti-seizure medications?* Yes No What Type?* When was their last dose?* Does your pet have a history of allergies to any drugs or medications?* Yes No Please Explain:*Does your pet have a history of any illnesses or injuries we need to be aware of today?* Yes No Please Explain:*Is your pet currently taking any medications? Including any preventatives or supplements.* Yes No Please list medications or supplements and when their last dose was given.*Please note if any fleas or ticks are found on your pet while in the hospital, they will be treated at an additional cost to you. Dental Extractions It can be difficult to predict if teeth need to be extracted when an animal is awake because tartar and movement interfere with assessment. Severe dental disease and damaged teeth can cause considerable pain and discomfort to your pet. They are, also, a potential source of infection for other organ systems (liver, kidney, lungs, and heart). During the dental cleaning, the teeth will be evaluated by the attending veterinarian to determine if extraction is necessary. The cost of these extractions may range from $40-110 per tooth depending on the amount of time taken to remove the tooth and the difficulty of the extraction.Please choose one of the following options* I authorize all medically necessary extractions to be performed. I authorize all medically necessary extractions within a numerical constraint. I prefer to be called prior to any extractions being performed. Numerical Constraint:*I understand if I cannot be reached in a timely manner, no extractions will be made and an additional procedure with anesthesia may be required in the near future, resulting in additional cost to me.* I Understand Optional Procedures Nail Trim ($24) Anal Gland Expression ($28) Ear Cleaning ($34) Ear Hair Removal ($28) Microchip ($47.50) CPRI am mindful that during the operation/procedure, unforeseen conditions may arise that may require the performance of additional procedures deemed necessary by the veterinarian. I am encouraged to discuss any concerns I have about these risks with the attending veterinarian before the procedure is initiated.* I have read and agree. In the event your pet should experience cardiac or respiratory arrest while being hospitalized today, do you give consent for resuscitative efforts to be initiated until you can be contacted further and notified of your pet’s status? By consenting to this service, you are also acknowledging that certain fees will apply. If you are not able to be contacted immediately, resuscitative efforts will continue to be performed at the doctor’s discretion.* I agree to CPR being performed in case of arrest. I elect a “Do Not Resuscitate” status in case of arrest. For the safety of your pet and others, we ask that all animals coming into the building be restrained by a leash or in a carrier upon arrival. Those individuals without proper restraint may request assistance upon arrival. Acknowledgements I am the owner or authorized agent for the pet described above and have the authority to execute this consent. By signing this document, I certify that I am over eighteen years of age. I agree to make myself available by phone between the hours of 8:30am – 2:30pm. I hereby agree that I have been informed of and understand there are certain risks and possible complications associated with dental procedures and the anesthesia or sedation associated with those procedures, and after being informed of the nature of the dental procedure and those services elected by me, I understand what will be done for my pet. I am mindful that while Hub City Vet provides the highest quality of anesthesia, surgical and dental services, it is possible that during the operation/procedure, unforeseen conditions may arise that may require the performance of additional procedures deemed necessary by the veterinarian. I fully acknowledge and understand these risks, knowing that the hospital and the hospital staff will do all that is necessary to minimize these risks. Additionally, I authorize Hub City Vet Clinic to perform any diagnostic, medical treatment, surgical procedure, or dentistry as deemed necessary for any unforeseen medical or surgical complications if one should arise. I will hold harmless and without blame Hub City Vet Clinic, the veterinarian, or any hospital staff members for any complications that should arise during my pet’s medical treatment and care. I am encouraged to discuss any concerns I have about these risks with the attending veterinarian prior to the procedure taking place. I authorize the use of appropriate anesthesia and pain relief medications as needed before, during, or after the procedure. I have been informed that there are risks associated with the use of any medications. I understand the practice of veterinary medicine is not an exact science and thus, there are no warranty or guarantees that can be awarded to me as to the results or cure afforded by the treatments or procedures performed today. I have been awarded the opportunity to discuss any questions I may have regarding the care of my pet to my satisfaction, and it is my responsibility to do so. I accept that my financial obligation remains regardless of any outcome. I will not hold liable Hub City Vet Clinic, the veterinarian, or any hospital staff members for the loss or damage of any personal items (leashes, collars, blankets, etc.) that is left at the hospital. If I neglect to pick up my pet or any personal items within a 5-days from the date below, Hub City Vet Clinic will assume abandonment of my pet or personal items. By signing this consent form, I agree to pay in full by the end of business today for services rendered, including those deemed necessary by the veterinarian for any medical complications or unforeseen circumstances. Furthermore, I understand regardless of the outcome of treatment, I am responsible for payment of the procedures performed today. If for any reason there are financial restrictions associated with this visit, it is my responsibility as the owner to notify a staff member immediately of such limitations.(Initials) I have read and understood this authorization and acknowledgements, and I hereby accept and consent to its terms and to the treatment of my pet.* Signature*Date* MM slash DD slash YYYY CAPTCHANameThis field is for validation purposes and should be left unchanged.