Name *

First

Last

Phone Number *

Email

Other individual authorized to make decisions about my pet:

First

Last

Additional Phone Number

Procedure

Surgical Procedure *

Procedure Date *

Patient Name *

Patient Age *

Patient Sex *

Patient Breed *

What has your pet had to eat and drink today? *

When was the last time they had something to eat or drink? *

Is your pet on any medications or supplements? Please provide a complete list. *

Additional Treatment

These procedures, the medical necessity and costs have been explained to me to my satisfaction. I understand that I may call for updates on my pet as I deem appropriate. I understand that no guarantee has been made to me regarding the outcome of my pet’s treatment or procedure. 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 is initiated. Should some unexpected life-saving emergency care be required and the attending veterinarian is unable to reach me, I: *

CONSENT to additional life-saving treatment at the discretion of the attending doctor and agree to pay for all related fees. I accept that veterinary medicine is an inexact science and that no guarantee of successful treatment has been made.
DO NOT CONSENT to additional life-saving treatment at the discretion of the attending doctor and agree to pay for all related fees. I accept that veterinary medicine is an inexact science and that no guarantee of successful treatment has been made.

Dental Extractions

Extractions are done at our doctor's discretion based on their medical expertise. We do not call before we extract. Teeth that need to be extracted cannot always be fully identified until the pet is under anesthesia, so the provided estimate may not include all the necessary extractions. The doctor will only extract teeth if they have any of the following issues: severe dental disease, cavities with exposed root/pulp, severe cracks or fractures, dead teeth or teeth with advance mobility. *

I CONFIRM that I understand the extraction policy and that it may change the cost on the provided estimate

Pre-Anesthetic Blood Testing

Our greatest concern is the well being of your pet. We will monitor your pet’s heart rate, respiratory rate, pulse oximetry, temperature, and blood pressure during surgery. This technology, along with pre-anesthetic blood screening, reduces many of the risks of surgery. We strongly recommend pre-anesthesia bloodwork prior to anesthetizing your pet. Many conditions, including disorders of the liver, kidneys and blood may not be detected unless blood testing is performed. Please select one of the following: *

Yes, I want a CBC and pre-anesthetic chemistry ($121) OR
Yes, I want a CBC and full chemistry ($226)
No, I am aware of the risks and I am declining bloodwork.

Microchip

If your pet does not already have a microchip for identification, would you like us to implant one while they are under anesthesia? These microchips are added to our software and to a national registry so your pet can be identified if they get lost. *

Yes, please implant a microchip in my pet. ($51.99)
No, thank you.

Post Operative Laser Therapy

We recommend photobiomodulation (laser therapy) to help alleviate inflammation and speed healing. This is typically used for arthritis or other types of chronic inflammation, but we also use it on the gums after dental scaling or extractions. Please select from the options below: *

Yes, please use the therapy laser on my pet's gums. ($17.37)
No, thank you.

Elizabethan Collar

An elizabethan collar will be sent home with your pet in the case of extractions. If you do not want an elizabethan collar, you must decline it below: *

Yes, I will take an elizabethan collar home today.
No, I decline an e-collar. Do not send one home with my pet.

Picture Message/Text

If time permits, would you like a picture message of your pet sent to your cell phone after the surgical procedure? (Your carrier charges may apply) *

Yes
No

Can we use photos of your pet on our social media pages? *

Yes
No

Financial Responsibility

I understand that an estimate of the costs for veterinary services will be provided to me and that I am encouraged to discuss all fees related to such care before services are rendered and during this pet’s ongoing medical treatment. If my pet is hospitalized, I agree to pay a deposit of 60% of the estimated fees on the provided estimate at the time of hospitalization and assume financial responsibility for the balance of all services rendered, due in full on a cash, credit card, CareCredit, ScratchPay or check basis at the time your pet is discharged. If my pet is hospitalized beyond the first day at this facility, I understand that veterinary care during nighttime hours and/or weekends is provided at the discretion of the attending veterinarian. Continuous presence of personnel is not provided during these hours. If I desire that my pet have supervision when this facility is closed, I may elect to transfer to a local emergency clinic, at my expense, where overnight veterinary supervision is available. PLEASE NOTE: Our hospital policy is to keep all surgery patients overnight unless you are informed otherwise by a Doctor or other member of our team. *

Yes
No

Surgical Consent

I, being responsible for my pet, having the authority to do so, grant my consent to receive treatment, prescribe for and/or operate upon my pet as noted above. I also agree that after consultation with me, the hospital’s doctors may prescribe medication for, treat, hospitalize, sedate, anesthetize and/or perform surgery on the animal. Lone Tree Animal Care Center is to use all reasonable precautions against injury, escape or death of my pet, but is not held liable or responsible in any matter, as I thoroughly understand I assume all risks. I, the undersigned owner, authorized agent of the owner or Good Samaritan responsible for seeking veterinary care for my pet certify that: *

I AM over eighteen years of age
I AM NOT over eighteen years of age

Signature of Owner or Authorized Agent *

Clear Signature

Signature Date *

Dental Consent Form

Procedure

Additional Treatment

Dental Extractions

Pre-Anesthetic Blood Testing

Microchip

Post Operative Laser Therapy

Elizabethan Collar

Picture Message/Text

Financial Responsibility

Surgical Consent

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