Legal Owner Name (must be over 18 years of age) (Required)
Secondary Emergency Contact Name (Required)
Will someone other than the above named person be dropping your pet off for surgery? If yes, what is their name and are they authorized to give consent on your behalf? (Required) Do the doctors employed by Healing Paws Veterinary Care, Inc. have permission to do treatments not listed on the treatment plan if the doctor feels they are in the best interest of your pet and, after trying both numbers and leaving messages, is unable to contact you within 20 minutes time of the initial call and feels that theses tests and treatment are necessary for the best care of your pet? (Required)
(If no, the treatment may have to be scheduled on another day, which may result in additional expenses or a change in your pet's condition)
Has your pet vomited or had any changes in breathing in the last week? (Required) Has your pet developed any new medical symptoms? Do you have any concerns about their health? (Required) Please List All Medications, Treatments, Supplements Currently Being Given, and the time of day you typically give them. IT IS VERY IMPORTANT THAT YOU LIST AS MUCH DETAIL AS POSSIBLE, INCLUDING THE NAME OF THE MEDICATION, THE MG OF THE MEDICATION, and HOW MANY TABLETS/CAPSULES/ML even if you buy them here. (Required) A microchip is a tiny, rice-grain-sized implant that goes under the surface of your pet's skin using a needle. The microchip has a unique number that can be read by a special scanner. While collars can come off and ID tags can get lost, a microchip is a permanent form of identification. If it gets separated from you and is found, animal control or veterinary clinics can scan your pet's microchip, and the number is used to look up your contact information. Would you like us to implant a microchip while your pet is here today? Do you have anything else that is not included in your current treatment plan that you would like addressed (if medically advisable) for your pet today? (please list: anal glands expressed, ears checked, etc.) (Required) Would you like us to refill your pet's heartworm/intestinal parasite/flea/tick preventative while they are here? If so, would you like a 6 or 12 month supply, and which brand do you prefer? (Required) Do you have any other questions prior to your pet's procedure? (Required) It is extremely important that you are reachable by phone the day of the procedure. In the case of medical emergencies and unexpected treatment decision making, the doctor will need your permission and time is critical both during medical emergencies and when a pet is anesthetized.
In the unlikely event that the above-named pet should experience cardiac or respiratory arrest while being hospitalized today, we need to know, in advance, what your wishes are for your pet. If your pet does experience anesthetic difficulty, cardiac or respiratory arrest, we will absolutely contact you. However, your pet's safety and well-being come first, so we need you to direct us here as to your wishes for their care.
Cardiopulmonary Resuscitation (CPR):
All resuscitative efforts are to be attempted to restore normal heart function and to breathe as deemed necessary by the doctor until I can be reached. Should my pet require cardiopulmonary resuscitation (CPR), I request that the doctor(s) pursues medical care. I understand that this is a cost in ADDITION to any estimate, and I agree to pay this fee. The cost of full CPR is typically at least an additional $300 or more and in no way guarantees that my pet will survive their cardiac or respiratory event. Patients who require CPR typically need at least 24 to 48 hours of intensive care and monitoring at a specialty facility following resuscitation. It will be necessary for me to transport my pet to the specialty facility and I will be responsible for the charges for my pet's care at that facility.
Do Not Attempt Resuscitation (DNR):
No cardiopulmonary resuscitation (CPR) efforts will be performed in effort to save my pet if they have cardiac or respiratory arrest, only the administration of medication to help ease my pet's passing may be used.
Please add your initials next to the option you'd like the doctors to proceed with Please select the option you'd like the doctors to proceed with. Important Information About Anesthetic Procedures at Healing Paws Veterinary Care
Patient must be current on Rabies vaccination, fecal ova and parasites testing, as well as have a current canine Heartworm/Lyme/Ehrlichia/Anaplasmosis test or Feline Leukemia/Feline Immunodeficiency virus or these procedures will be performed today at my expense.
All patients under anesthesia will have a physical examination, anesthetic, and recovery monitoring, fluid therapy, and pain management during their stay.
If live fleas, flea larva, or flea dirt is found on my pet, they will be administered a medical flea and tick preventative while at Healing Paws Veterinary Care, and I will be responsible for the cost of that product even though it is not listed in my treatment plan.
All anesthetic patients should have a small meal between 10 pm and midnight the night before their procedure, and then they should not receive any food or treats after that time unless otherwise directed by their doctor.
All anesthetic patients should have access to water at all times (including the morning of their procedure) unless otherwise directed by their doctor.
All anesthetic patients should receive their normal medications as well as their pre-anesthetic medications that were sent home at their anesthesia preparatory visit at their normal schedules unless otherwise directed by their doctor. Pets that require morning medication should be given that medication manually or with no more than one total teaspoon of food as food can induce vomiting during anesthesia. If you are unable to give your pet their morning medication, you must bring it along with you to the appointment, and you may need to take your pet home and reschedule their visit for another day.
Please check below. (Required) Authorization to Perform Surgery and/or Treatment I have received a treatment plan detailing what is planned on being performed for my pet's medical care today. I realize that this plan has estimated costs, but that with pets and with medicine, sometimes unexpected situations arise and alterations to this plan must be made for the best care of my pet. I hereby authorize the clinic to perform such anesthetic and surgical procedures as described above and listed on the treatment plan. The nature of such services has been described to me to my satisfaction and I realize that no guarantee or warranty can ethically or professionally be made regarding outcomes of treatment of medical illnesses. I have been informed that there are certain risks and complications associated with sedation, anesthesia, and/or any operation/procedure and that the risks/complications have been explained to me. I further understand that during the course of the operations or procedures, unforeseen conditions may arise that may necessitate 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. (Required) I am the owner or the authorized agent for the owner of the animal described above, and I have the authority to execute this consent. My signature below certifies that I am over eighteen years of age. (Required) The nature of these operations or procedures has been explained to me and I understand what will be done. I am aware that the practice of veterinary medicine is not an exact science and, thus, there are no guarantees for successful treatment. I have been encouraged and given the opportunity to discuss any questions I may have regarding my pet's medical care and my questions have been answered to my satisfaction. I accept that my financial obligations remain regardless of the outcome. (Required) Signature (Required)
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