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Elizabeth Danta Blount, DVM Phone: 850.274.5710 Fax: 850.216.2973 www.athomevetintally.net [email protected] P.O. Box 14101 Tallahassee, FL 32317 CONSENT TO TREATMENT AND/OR SURGERY Pet: _______________________________________ Date:__________________ 1. I am the owner/agent for the patient and have authority to complete this consent. 2. I consent to and authorize the performance of the following procedure(s) and/or surgery. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 3. I understand that during the performance of the above procedure(s) or surgery unforeseen conditions may occur that necessitate an extension of the above procedure(s) or different procedure(s) than those set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) or surgery as are necessary and reasonable in the veterinarian’s professional judgment. 4. I also authorize the use of appropriate anesthetics, antibiotics, vaccines and pain medications as deemed appropriate by the veterinarian and required by the policies of At Home Veterinary Care, LLC. 5. I have been advised of the nature of the procedure(s) or surgery and the risks involved. I realize that results cannot be guaranteed and that the use of anesthetics, medications and/or surgery can result in complications, including death. 6. I understand that I am financially responsible for all charges incurred in the treatment of my pet, and that in the event of development of an illness or emergency that requires additional treatment, additional charges will apply. I understand that payment in full is required at the time of my pet’s discharge, unless arrangements are made in advance. 7. Pre-anesthetic bloodwork is recommended for all pets undergoing anesthesia/surgery, as it allows us to have the best assessment of your pet’s overall health and assist us in selecting the safest treatment prcedures. Specific Recommendations: Pre-anesthesia mini screen ____________ Heartworm Test _____________ Feline Leukemia/AIDS/Heartworm Test____________ Complete Blood Profile______________ Complete Health Screen______________ Geriatric Health Profile_______________ I decline pre-anesthesia testing at this time. _____________ 8. I understand that estimates of charges are only estimates and NOT A GUARANTEE of final charges. Charges depend on treatment/services actually rendered. Reasonable attempts will be made, in advance, to obtain approval for additional services. Contact Telephone Number for Today____________________ 9. I have read and do understand this consent. Witness to Signature Signature of Owner/Agent ___________________________________ ______________________________________