Consent Form - Animal Hospital | Pet Care - Wilkes Barre, PA

Client Information

Client's Name*

First Last

Email*

Phone*

Phone number of person bring pet to appointment, if different than above.

Date*

Pet's Name*

Age*

Sex*

Species*

Dog
Cat
Other

Procedure(s)*

Visit Information

Date and time of my pet's last meal*

Have you administered any medication, supplements, or vitamins to your pet in the last 48 hours?*

Yes
No

Which medication(s)?*

What dose and strength?*

When was the medication given?*

How many tablets, capsules, or ccs were administered?*

Do you use flea and tick prevention on your pet?*

Yes
No

What type and when was it administered?*

Do you administer heartworm prevention to your pet?*

Yes
No

What type and when was it administered?*

I would like to add the following elective procedures to my pet's visit*

Nail Trim ($20.00-$45.00 | No charge if pet is under anesthesia)
Anal Gland Expression ($20.00)
Microchip Implantation ($40.00)
Ear Cleaning ($15.00)
4DX Snap Test ($59.00)
Feline Aids/Leukemia Test ($55.00)
Vaccines (if due)
Other
None

Other*

Pre-Anesthetic Diagnostics*

My pet has already had pre-anesthetic blood work
My pet has already had pre-anesthetic x-rays
I approve pre-anesthetic blood work
I approve pre-anesthetic x-rays
I decline
Not Applicable

Baby Teeth Extraction

Small breed pets often suffer from retained deciduous (baby) teeth after their adult teeth grow in. This condition creates overcrowding of teeth, retention of food or other debris between the teeth, and tartar buildup. This, in turn, leads to bad breath and damage to gums and adult teeth. We strongly recommend that these deciduous teeth be extracted while your pet is under anesthesia to avoid future complications. The cost for this procedure varies based the number of teeth extracted.

I approve my pet's baby teeth to be extracted if present*

Yes
No
Not Applicable

Consent

I certify that I am the owner, or authorized agent for the owner, of the above animal. l hereby consent to and authorize the doctors and staff at this veterinary practice to admit this pet, perform the above described procedures, and administer medications, anesthesia, surgical procedures, tests and/or treatments that the doctors deem necessary for its health, safety and well being while under their care and supervision. I have been advised of the nature of the procedures and the potential risks and benefits. I understand that veterinary medicine is an inexact science and that no guarantee of successful treatment can be made.

Photograph Release: I hereby grant Shoemaker Avenue Animal Hospital permission to take photographs of my pet and to publish those photographs for any lawful purpose, including but not limited to their website, social media accounts and promotional materials, either digital or in print, in perpetuity. I also grant permission to use my name and/or my pet’s name. By signing and dating this document I authorize Shoemaker Avenue Animal Hospital to edit, alter, share, remix, tweak, build upon or in any way alter the photograph(s) mentioned above. I also waive any rights of privacy or compensation associated with the use of my pet’s image(s) and name(s) for personal, educational or commercial purposes outlined above.

I acknowledge that I am responsible for payment in full for the above procedures and treatments at the time my pet is discharged.

CPR in the event of cardiac arrest.*

In the event of cardiac arrest, I elect to have CPR performed on my pet. I understand this may result in additional charges up to or beyond $300.
In the event of cardiac arrest, I DO NOT want CPR performed on my pet.

Signature*