Surgery/Anesthesia Waiver Form Authorization for Professional Services and Anesthesia Waiver Authorization for Professional Services and Anesthesia Waiver Owner's Name * Owner's Name First First Last Last Pet's Name * Pet's Age * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Email * Phone number where you can be reached today * Preferred method of contact for updates * Email Phone Text Procedure(s) to be performed Elective procedures while your pet is in our care Microchip - ($47.00) Microscopic Fecal Exam - ($36.25) 4dx Test (hwt + tick borne illnesses) - (44.40) Feline FELV/FIV Test - ($58.90) Post Op Laser Therapy - (Additional $10) Flush and Clean ears - ($23.00) Anal Gland Expression - ($25.00) Presurgical ECG - ($102.75) Lump/Wart Removal (prices start at $100) Vaccinations Note how many and where located Select which vaccinations are needed KC Rabies DHPP Lepto FVRCP FELV Current Medications Other Procedures *Please note, complimentary toe nail trims are performed on all anesthetized patients Do you give us permission to use your pet’s photos and videos for social media & educational purposes? Yes No Consent to perform extractions and other necessary procedures Some patients require IV catheters ($47.00) placed for medication administration, fluids and their safety while under anesthesia. It is required that the IV catheter site be shaved for this due to sterility. I understand and consent Occasionally, pets need to have teeth extracted for their long-term comfort and health. We will only extract the tooth if it is medically necessary and cannot be repaired. There are additional costs associated with this oral surgery. Your pet will receive pain medications if he or she has a tooth or teeth extracted and you will also receive instructions post-surgically from your technician or doctor. * I understand and consent DNR (Do Not Resuscitate) Request: By checking this box, I am declining a DNR request and understand that I am financially responsible for any costs associated with necessary life-saving measures. I also acknowledge that life-saving measures do not always guarantee a successful outcome, and the effectiveness of such measures can vary based on the nature and severity of the pet's condition. I am declining DNR Please read below and sign I hereby authorize American Animal Hospital to perform such diagnostic, therapeutic and surgical procedures as are, in their opinion, necessary and advisable for treatment and maintenance of my pet’s health and well being. The nature of such services has been described to me to my satisfaction and, while I expect all procedures to be done to the best of the abilities of the professional staff, I realize that no guarantee or warranty can ethically, or professionally, be made regarding the results or cure. I also authorize the hospital director and staff to provide veterinary service as required, or in emergency circumstances, to follow through with such procedures as are necessary for the well being of my pet on a continuing basis until further advised in writing. I understand that I assume full financial responsibility for all services rendered. Signature * signature keyboard Clear Date * Captcha Submit If you are human, leave this field blank.
