Authorization | Veterinary Authorization

Anesthesia + Surgery Authorization Form

First and Last Name:*
Today’s Date*
Date Format: MM slash DD slash YYYY
Pet’s Name*
Current medications:*
Please provide medication name, dose, how often it is given, and when it is given. Please ask your veterinary team if the medication should or should not be given prior to the procedure. (Write "none" if your pet does not receive any medications).
Diet:*
In the event your pet is advised to stay in the hospital after their procedure, what type of food do they eat, how much, and how often?
I have been provided a copy of my pet’s Care Plan & Estimate of Cost*
- Yes
- No
Dental procedures only - If more extractions are required than originally estimated after x-rays are performed, please proceed with extractions without calling me first.*
- Yes - proceed with extractions and call me after the procedure is complete; I understand there will be higher costs associated with more extractions.
- No - please call me during anesthesia to ask for permission for additional extractions beyond the estimate.
- Not applicable; my pet is not undergoing a dental procedure.
This allows us to continue working on your pet's teeth to shorten anesthesia time as much as possible. More extractions will incur higher costs.
Consent*
I authorize the Care Plan, Estimate of Cost, and understand possible risk associated with anesthesia and/or surgery.*
I hereby acknowledge that I have full authority of this pet and direct Chris Reagh DVM, Andrea Mears DVM, Judi Vinch DVM, Staci Schroeder DVM, Kelly Zilli DVM, or Chantel Raghu DVM to perform the procedure and additional diagnostic and /or treatment procedure deemed advisable or necessary. I understand there may be risk involved in these procedures. Be assured that the health of your pet is our highest concern and we will do everything possible to maintain that health. The provided Care Plan & Estimate of Cost only approximates the cost of the visit. It does not include any treatments that may be deemed necessary upon examination and commencement of the included treatments. You (client) will be responsible for all fees incurred during this visit included or not on the Care Plan. If fleas and/or parasites are found during the exam, there will be an additional charge for treatment.Your signature below indicates that you have reviewed and agree to the terms above.
Fasting after midnight:*
I understand that no food should be given after midnight the night before the procedure but water is okay to have available. If your pet is diabetic, very young, a rabbit or pocket pet (such as a rat), or needs an emergency procedure, then please follow your veterinary team's recommendation on fasting.
Microchip wanted?*
Please let us know if you would like a microchip placed while your pet is under anesthesia.
If a microchip is wanted, please let us know who to register as the secondary emergency contact (cannot be the same as the primary contact person):
Please list their first and last name and phone number.
Signature*
Date*
Date Format: MM slash DD slash YYYY
Primary person to contact with medical questions:*
Please list the best phone number and name of person for medical questions.
Person to contact for pick up after anesthesia:*
Please list the best phone number and name of person for pick-up after the procedure. Write "same" if it is the same answer as the previous question.
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