Home Pre-anesthetic Submittable Form

Pre-anesthetic Submittable Form

Client Name

Pet's Name

Phone number at which owner can be reached

Additional Number

After procedure

Would you like us to call you with an update and potentially adjusted discharge time?

I, the undersigned owner or agent of the pet identified above, authorize the staff of Animal Clinic of Mandarin to perform the procedure(s) as outlined by Dr Kaiser and the staff at the Animal Clinic of Mandarin.

I have read and agree I have read and agree No, I do not agree

Have you given your pets any medications or supplements in the past week? Yes No

If yes please specify

I acknowledge that my pet has not been fed at least 2 hours before drop off I acknowledge I do not acknowledge

Any other concerns/allergies/procedures?

Drop a photo of a product

Anesthesia Consent

I understand that some risks always exist with anesthesia and/ or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated.

Please select I have read and agree I do not agree

I authorize Animal Clinic of Mandarin to administer sedatives and/or general anesthesia on my pet for the services or procedures outlined in the associated treatment plan. I have discussed the plan for anesthesia with a veterinary professional to my satisfaction and am aware I may contact the Animal Clinic of Mandarin with my questions. I understand that anesthesia poses a risk to my pet, regardless of health status and this risk can be minor or life threatening in rare situations. In the event of unforeseen complications, I give permission for the doctors and staff to take reasonable measures in treating my pet and accept all charges that are incurred as a result of such action I am over 18 and understand that the attending veterinarian will make every effort to contact me regarding treatment in the case of unforeseen situations but in life threatening emergencies this will often not be possible.

I authorize

In the Event of Cardiac Arrest During Hospitalization (heart or breathing stops)

Custom Field I request emergency and life-saving procedures (including cardiopulmonary resuscitation) be performed immediately on my pet. I understand I will not be contacted prior to these actions and now give permission for the doctors and staff to take reasonable measures in treating my pet. I accept all additional charges that are incurred as a result of such action. I understand initiating CPR does not guarantee survival. I understand that CPR in pets that have arrested have a low probability of survival and that the cost associated with this treatment is often extensive. I do not request emergency and life saving procedures

I authorize Animal Clinic of Mandarin to perform the procedure(s) outlined in the associated treatment plan on my pet. I understand the itemized treatment plan is a good-faith representation of what will be performed during this procedure. If the veterinarian encounters medical conditions that require additional treatment, I authorize the doctor to move forward as follows :

Custom Field I authorize up to 250 dollars. I authorize up to 500 dollars I authorize up to 1000 dollars.

Custom Field

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow up radiographs, re-check physical exams and additional surgery due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions. I have been provided an estimated cost for the procedure(s) listed above. I assume financial responsibility for the recommended services and will provide payment in full at the time my pet is discharged from the hospital. I have read and fully understand the terms and conditions set forth above.

Custom Field

Location

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Office Hours

Our regular schedule

Primary Location

Monday:

08:00 am - 06:00 pm

Tuesday:

08:00 am - 06:00 pm

Wednesday:

08:00 am - 12:00 pm

Thursday:

08:00 am - 06:00 pm

Friday:

08:00 am - 06:00 pm

Saturday:

Closed

Sunday:

Closed