Download COMPANION PET CLINIC

COMPANION PET CLINIC-SALMON CREEK
“Full Service, Quality Veterinary Care at Affordable Prices”
AUTHORIZATION FOR DENTAL TREATMENT
I, the undersigned, owner/agent of admitted patient hereby authorize the Doctors of Companion Pet Clinic (and whomever they may
designate) to administer such treatment(s) as necessary, and to perform the following procedures: DENTAL and such additional
procedures as are considered therapeutically and/or diagnostically necessary on the basis of findings during the course of a physical
evaluation. The treatment or procedure is to include whatever is necessary to accomplish the purpose, including but not limited to
the administration of drugs and anesthetics. I, therefore, consent to the administration of such drugs and anesthetics as are necessary.
Anesthetic risk: I understand that all anesthetics present some risk of complications and serious possible damage to vital organs and
that in some cases may result in paralysis, cardiac arrest and/or brain damage, or death, from both known and unknown causes. I
understand that Companion Pet Clinic and its Doctors reserve the right to treat any complications and or problems that may arise
from the surgical procedure or medical treatment performed on my pet. I realize that no guarantees, nor warranty can ethically or
professionally be made and I acknowledge that no assurances have been made to me concerning the results of this treatment and/or
procedure. I understand the risks and I request this treatment and /or procedure and waive any and all claims of damages against
Companion Pet Clinic, it’s Doctors, and employees in the event of complications, injury or death of my animal. If for any reasons
the agreed fees are changed due to complications, I will agree to pay for such charges if contacted by telephone. In case such contact
is impossible or infeasible, I agree to pay charges only if my pet’s life was in jeopardy. Should charges not be paid when due, I
promise to pay in addition all costs of collection and a reasonable attorney’s fees, whether or not a suit is filed upon. All delinquent
accounts bare interest at the legal rate.
I realize that in many cases it is impossible to determine in advance the extent of medical or surgical treatment required, but in such
cases Companion Pet Clinic will attempt to estimate the cost of treatment. It is understood that the actual cost may exceed or be
lower than the estimate. I certify that I have read the foregoing and agree to all terms and that I understand all that I have read and
have had any terms that were unclear explained to me.
I understand that Companion Pet Clinic does not accept checks. The clinic accepts cash, Visa, MasterCard, Discover, American
Express and Debit Cards.
Owner or Party Assuming Responsibility___________________________________ Date _________________
Pet’s name___________________________________ Emergency Phone #______________________________
If we are not able to reach you, your pet’s procedure may not be performed and may need to be rescheduled.
I understand patients that are admitted for elective surgeries may not be released by the close of business
day. Call after 3:00 PM to check the status of your pet. INITIAL ___________
Your pet is in for anesthesia/surgery and should do fine. We will perform a brief physical exam on your pet before
administration of anesthesia. However, we highly recommend a pre-operative blood profile for the purpose of
ensuring your pet to be in a low risk category during anesthesia. This blood test is an indicator of dehydration,
anemia, kidney function, and liver function. By performing this pre-operative blood profile we will be able to
rule out any pre-existing problems that may not be evident physically, but could lead to complications. There
is an additional fee of $133.84 for this important procedure. Please indicate your choice by signing the
appropriate response.
PLEASE COMPLETE the blood work
you recommend prior to surgery, and
call me if there are any abnormalities
found.____________________________
I ELECT TO DECLINE the pre-op
blood work at this time and request
you to continue with the scheduled
procedure______________________
Has patient been fasted (not eaten)? _____ Food pulled (time) ______
Has patient had any medication in the last 24 hours? Yes______ No_______
In an EMERGENCY situation, if treatment is needed before reaching you, please indicate if you YES I DO OR
NO I DO NOT want emergency resuscitation procedures to be performed on your pet. (note there could be
additional costs.)
INITIAL YES___________ NO _________
Should we note live fleas on your pet while in hospital we will apply a dose of flea preventative for an additional
charge. INITIAL________
Would you like your pet to receive an injection for pain for the surgical procedure? The injection lasts between 12
to 24 hours and costs: Felines $30.75, Canines starting at $27.37(+/- depending on weight)
INITIAL YES _________ NO ________ IF EXTRACTION_______
Would you like your pet to receive an ISO microchip with prepaid registration while under anesthesia? The cost
is $49.23?
INITIAL YES_________ NO ________ my pet already has a microchip________
Would you like your cat tested for FELINE LEUKEMIA/FIV , for a cost of $58.29?
INITIAL YES _________ NO _________
Would you like your pet tested for HEARTWORMS, for a cost of $33.68?
INITIAL YES _________ NO _________
Would you like your pet to have an I.V. CATHETER WITH FLUIDS, for a cost of $99.63?
INITIAL YES _________ NO _________
(Doctor highly recommends for thin breeds, no body fat).
I understand if my pet requires any teeth extractions there will be additional charges, which can range by difficulty.
Deciduous Extraction: $25.30
Premolar Extraction: $84.90
Pre Radiograph: $27.54
Loose Extraction: $12.72
Molar Extraction: $68.00
Post Radiograph $13.50
Incisor Extraction: $33.97
Canine Extraction: $110.00
Initial__________
Is your pet current on his/her vaccines?__________
If no, Please initial by the vaccine (s) you would like your pet to receive today.
CANINE
FELINE
DHPP......……………………$13.85 ________
FVRCP……………….$10.45 _______
BORDETELLA……………..$12.95 _________
FELV…………………$15.45 _______
LYME……………………….$21.82 _________
*RABIES……………..$9.55 ________
*RABIES……………………$9.55 __________
*Rabies is mandatory without proof of vaccination
Would you like your pet to have a NAIL TRIM, there is no charge while under anesthesia?
INITIAL YES_________ NO _________
I understand that antibiotics or additional pain medications may be sent home. INITIAL ________
If you have any requests or concerns today please list them below. (i.e.- Check lump on back left leg)
(If a thorough exam is required then there will be an exam fee of $29.50)