Name *

First

Last

Email *

Primary Phone *

Pet's Name *

Species

Canine
Feline
Other

Other species: *

Breed *

Color *

Age/Date of Birth *

Sex *

Male
Neutered Male
Female
Spayed Female

Procedure (check all that apply) *

The nature of these services has been described to my satisfaction and I realize that no guarantee nor warranty can ethically or professionally be made regarding the results or cure.

Other Procedure *

ANESTHESIA DISCLAIMER - I understand that anesthesia carries some risk (even though it may be small). To help further minimize that risk, a pre-surgical blood panel that screens organ function will be run on your pet before anesthesia. Most anesthetic agents are removed from the body by the liver and kidneys, so it is important to know before anesthesia that these organs are functioning properly. The preanesthetic blood profile helps us make this determination as well as helping to evaluate the overall health of your pet. If your pet has had such testing within the past thirty days with normal results, the test will not need to be repeated today. *

I have read and understand

POST-OPERATIVE PAIN CONTROL - Every animal experiences pain from surgery to a different degree. The doctors and staff of the Ark Veterinary Hospital, Inc. strive to ensure the comfort of every pet in our care. Any pet undergoing a procedure which may cause discomfort will be given a pre-operative pain medication injection and will be discharged with medication to provide continued relief during the home recovery phase. *

I have read and understand

MICROCHIPPING IDENTIFICATION - A simple and affordable procedure. Microchipped pets are much more likely to be returned to their homes should they become separated from you. While your pet is under sedation, would you like us to microchip him/her. Cost: $49.00 (There is also a one-time registration fee of $19.99 payable to Home Again) *

I have read and understand

Would you like us to microchip your pet?

YES, Please Microchip my pet.
NO, I do not wish to Microchip my pet at this time/my pet is already microchipped.

E-COLLAR - It is very important that your pet not lick it’s incision excessively. If you feel this may be an issue for your pet, please let us know. *

I have read and understand

E-Collar

YES, I feel an e-collar will be needed (charge per size).
NO, I do not think it will be necessary, but will call if I notice any excessive licking

Signature *

Clear Signature

By signing, you agree to the above procedures and authorizations.

Today's Date *

Patient Authorization Form

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