"*" indicates required fields Client Name* First Last Primary Phone*Secondary PhoneEmail Address* Pet's Name* Surgical Procedure* Neuter Spay Tumor Removal General Sedation Other Please select from the following options for further diagnostics on the growths to be removed.* Histopathology In-clinic cytology Decline further diagnostics Additional Surgical Procedures Retained Baby Teeth Hernia repair Please describe the procedure to be performed*General Patient History and InformationDid your pet eat this morning?* Yes No How Much Did They Eat?When did they eat?*Is your pet current on vaccinations (choose dog or cat)?* Dog Cat Rabies?* Yes No Please note if your pet is not current on their Rabies vaccination, they will receive a vaccine today.DHPP?* Yes No Bordetella?* Yes No CVRP (Upper Respiratory combo)?* Yes No Leukemia?* Yes No Is your pet current on heartworm preventative?* Yes No Has your pet had a heartworm test withing the past year?* Yes No Has your pet ever had fleas or ticks?* Yes No Is your pet currently on prevention for fleas and ticks?* Yes No Please note if any fleas or ticks are found on your pet while in the hospital, they will be treated at an additional cost to you.Has your pet experienced any vomiting or diarrhea within the past two weeks?* Yes No Vomiting, Diarrhea, or Both?* Vomiting Diarrhea Both When did you notice it?*Has it Resolved?* Yes No Has your pet experienced any coughing or sneezing within the past two weeks?* Yes No Coughing, Sneezing, or Both?* Coughing Sneezing Both When did you notice it?*Has it Resolved?* Yes No Does your pet have a history of seizures?* Yes No When was the last seizure?* Is your pet currently on anti-seizure medications?* Yes No What Type?* When was their last dose?* Does your pet have a history of allergies to any drugs or medications?* Yes No Does your pet have a history of any illnesses or injuries we need to be aware of today?* Yes No Is your pet currently taking any medications? Including any preventatives or supplements.* Yes No Please Explain:*Does your pet have a history of allergies to any drugs or medications?Please Explain:*Does your pet have a history of any illnesses or injuries we need to be aware of today?Please list medications or supplements and when their last dose was given.*Is your pet currently taking any medications? Including any preventatives or supplements.Procedural Information and Hospital PolicyPre-anesthetic Blood Testing: Pre-surgical blood tests along with physical exams will enable us to assess and minimize the risk of anesthesia to your pet by creating a protocol tapered to your pet’s needs.Blood Work Completed?* Yes No Date Completed:* MM slash DD slash YYYY A CBC (complete blood cell count) will be run today prior to your pets procedure.Option Heartworm with Tick Disease Screen (Dogs only) Heartworm with Feline Leukemia and FIV Screen (Cats only) Blood Chemistry Panel Decline all diagnostic testing Monitoring:To minimize anesthetic risk, we monitor your pet’s heart rate, blood pressure, respiratory rate, temperature, and oxygenation throughout the procedure. Catheterization:For sterility, hair will be shaved over a vein on the leg so that an intravenous (IV) catheter can be placed. Blood pressure may lower during anesthetic procedures and fluid therapy aids in supporting your pet’s internal organ systems. It, also, allows immediate access to the vascular system in case of an emergency. Pain Management:The doctors will administer pain medications according to your pet’s needs before, during, and after the procedure. Some pain medications can incur an additional fee. Antibiotics:The doctors may administer antibiotics according to your pet’s needs. These medications may incur an additional fee.Option Nail trim Ear Cleaning Ear Hair Anal glands Microchip Shave down CPRI am mindful that during the operation/procedure, unforeseen conditions may arise that may require the performance of additional procedures deemed necessary by the veterinarian. I am encouraged to discuss any concerns I have about these risks with the attending veterinarian before the procedure is initiated.* I have read and agree In the event your pet should experience cardiac or respiratory arrest while being hospitalized today, do you give consent for resuscitative efforts to be initiated until you can be contacted further and notified of your pet’s status? By consenting to this service, you are also acknowledging that certain fees will apply. If you are not able to be contacted immediately, resuscitative efforts will continue to be performed at the doctor’s discretion.* I agree to CPR being performed in case of arrest. I elect a “Do Not Resuscitate” status in case of arrest. For the safety of your pet and others, we ask that all animals coming into the building be restrained by a leash or in a carrier upon arrival. Those individuals without proper restraint may request assistance upon arrival. The client has received a written estimate and has had the opportunity to review the estimate and ask any questions or express concerns, and that their questions have been answered to their satisfaction, and they agree to the amount of the estimate given. We try our best to provide the most accurate estimate, occasionally unforeseen circumstances may arise that may result in additional feesAcknowledgementsI am the owner or an authorized agent for the pet described above and have the authority to execute this consent. By signing this document, I certify that I am over 18 years of age. I agree to make myself available by phone between the hours of 8:00 am – 6:00 pm. I hereby agree that I have been informed of and understand there are certain risks and possible complications associated with operations and procedures and the anesthesia or sedation associated with those procedures, and after being informed of the nature of the operation or procedures elected by me, I understand what will be done for my pet. I am mindful that while Grand Central Veterinary Hospital provides the highest quality of anesthesia and surgical services, it is possible that during the operation/procedure, unforeseen conditions may arise that may require the performance of additional procedures deemed necessary by the veterinarian. I fully acknowledge and understand these risks, knowing that the hospital and the hospital staff will do all that is necessary to minimize these risks. Additionally, I authorize Grand Central Veterinary Hospital to perform any such diagnostic, medical treatment, or surgical procedure as deemed necessary for any unforeseen medical or surgical complications if one should arise. I will hold harmless Grand Central Veterinary Hospital, the veterinarian, or any hospital staff members liable for any complications that may or should arise in my pet’s medical treatment and care. I am encouraged to discuss any concerns I have about these risks with the attending veterinarian prior to the procedure taking place. I authorize the use of appropriate anesthesia and pain relief medications as needed before, during, or after the procedure. I have been informed that there are risks associated with the use of any medications. I understand the practice of veterinary medicine is not an exact science and thus, there are no warranty or guarantees that can be awarded to me as to the results or cure afforded by the treatments or procedures performed today. I have been awarded the opportunity to discuss any questions I may have regarding the care of my pet to my satisfaction, and it is my responsibility to do so. I accept that my financial obligation remains regardless of any outcome. I will not hold liable Grand Central Veterinary Hospital, the veterinarian, or any hospital staff members for the loss or damage of any personal items (leashes, collars, blankets, etc.) that are left at the hospital. If I neglect to pick up my pet or any personal items within a 5-day time frame from the date below, Grand Central Veterinary Hospital will assume abandonment of my pet or personal items. By signing this consent form, I agree to leave a deposit in the amount equal to 50% of the estimate for services and pay the full balance due for services rendered by the end of the business day that I pick up my pet, including those deemed necessary by the veterinarian for any medical complications or unforeseen circumstances. Furthermore, I understand regardless of the outcome of treatment, I am responsible for payment of the procedures performed today. If for any reason there are financial restrictions associated with this visit, it is my responsibility as the owner to notify a staff member immediately of such limitations. ** Dental / surgical pick-up times are between 3:00 PM-6:00 PM ** I have read and understood this authorization and acknowledgements, and I hereby accept and consent to its terms and to the treatment of my pet.* InitialsSignature*Date* MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.