Please print out this form and bring it to the veterinary clinic at the time of
your appointment. In order to print, click the print button on the top of
your browser.

Thank you for giving us the opportunity to care for your pet.So thatwe may
become better acquainted, please complete the following:

Authorization for Treatment

OWNER:____________________________________DATE:______________

ADDRESS:______________________________________________________
    Street          City          Zip

PET'S NAME:________________________________

Your phone number for today:___________________________________

PROCEDURE TO BE PERFORMED TODAY:_______________________________

__________Cash   ___________Check   __________Visa/Master Card

Are vaccinations and laboratory tests current today?
(Within the last year)

DOGS

YES/NO                 UPDATE TODAY
__  __ Rabies               __
__  __ DHLP/Parvo           __
__  __ Bordetella           __
__  __ Heartworm Test       __
__  __ Intestinal Parasites __

CATS

YES/NO                 UPDATE TODAY
__  __ Rabies               __
__  __ FVRCP                __
__  __ Feline Leukemia      __
__  __ Intestinal Parasites __

YES/NO
__  __ Did your pet eat this morning?
__  __ Is your pet allergic to any drugs?
__  __ Has your pet had any illness or injury in the past 30 days?
__  __ Does your pet have any history of seizures and/or previous
       anesthetic problems?
__  __ Current medications _______________________________________

*PRE-SURGICAL BLOOD SCREEN CONSENT/WAIVER
Like you, our greatest concern is the well-being of your
pet.  A physical examination will be performed before
anesthetizing your pet.  However, many conditions,
including disorders of the kidneys, liver, heart & blood
cannot be detected without blood lab screening.  For this
reason, we highly recommend pre-operative screening before
sedating your pet.  Please initial the appropriate options
below:  (pre-surgical blood screen required on all
pets seven years of age or older).

_____I DO  _____I DO NOT authorize the recommended Pre-surgical
Blood Screen at a cost of $45.00.  I understand and assume all
responsibility for additional risks/complications resulting
from refusal to approve this blood screening for my pet's
safety.

ELECTIVE PROCEDURE TO BE DONE AT THE SAME TIME:
__ Dismissal Pain Medication
__ Dental procedures: __Extract Teeth as Necessary
                      __Scale/Clean Teeth/Fluoride Application
__ Heska Periodontal Treatment
__ Microchip Identification
__ Removal of wart or skin growth
__ Routine Toe Nail Trim
__ Ear Flushing
__ Other _______________________________________________

OWNER RELEASE
You are to use all reasonable precaution against injury,
escape, or death of my pet.  I understand all sedation/
anesthesia involves some minimal risk to my pet, but you
will not be held liable in any manner whatsoever or under
any circumstances in connection therewith as it is
thoroughly understood that I assume all risks.  I have read
the foregoing and agree:

__________________________________  Date____________________
  Signature of Owner/Agent