Rescue/Pet Shelter Surgery Consent Form – Chester Valley Veterinary Hospital

Rescue/pet shelter name *

Rescue/ pet shelter address *

Address Line 1

Address Line 2

City

State

Zip Code

Rescue/ shelter primary contact *

First

Last

Rescue/ shelter primary contact phone *

Rescue/ shelter primary contact email *

Foster/name of person bringing in pet *

First

Last

Foster/person bringing in pet's phone *

Pet's name *

Date of birth or estimated age

Species *

Breed *

Sex *

Male
Female

Spayed/neutered? *

Yes
No

Color/description

Microchip number *

Has your pet been seen previously by a veterinarian? *

Yes
No

Please have your previous veterinarian send all previous medical history for your pet via email (chestervalleyvet@healthypetalaska.com) or fax (907-337-4311) PRIOR to your scheduled appointment. Failure to have previous records prior to a scheduled appointment can result in both a delay in care and a medical records retrieval fee of up to $28.

Reason for visit *

Is your pet current on Rabies vaccine? *

Yes
No

*Must be able to provide proof today.

Do you think it is possible that your pet will bite or injure you while in the vet clinic? Please let us know so we can have staff prepared to help. *

Yes
No

Do you feel that your pet may bite or injure a staff member while at the vet? Please let us know so that we can keep all staff and animals safe. *

Yes
No

Do you have any physical limitations that would cause you to be unable to handle your pet inside the clinic? Please let us know so we can have staff prepared to help. *

Yes
No

If your pet is aggressive or reactive to people and/or other animals please keep them in your vehicle until you have checked in and your technician is ready to bring you and your pet directly into an exam room.

Additional information (destination address for a health certificate to travel) etc.

Current medications/herbal supplements

Recent emergency visits? Where was your pet seen?

Upload relevant medical records

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Signature *

Clear Signature

Date *

Primary contact for today's visit *

First

Last

Primary phone number for today's visit *

I hereby certify that I am the true and rightful/legal owner of the animal described above, no other person/group/shelter or rescue has any right of property in this animal. I assume full and complete rights, title, interests and decision making for the animal described above. *

I have read and attest to the above statement

Acupuncture Authorization: Pet acupuncture can be used to treat a host of issues, from pain, appetite stimulant, GI concerns, URI concerns and even sedation and anxiety. Acupuncture is the process of carefully placing special needles at certain points on the body in order to stimulate the nerves and lymphatic systems, as well as create complex interactions with the fascia layer and release of different chemicals and hormones in the body. This results in reduced pain and inflammation, and increased nerve function. Some patients may be slightly sore after treatment. It is not uncommon to also be more sedate after a treatment. I approve/decline the use of simple acupuncture as deemed fit for my pet by Dr. Tobiason. *

Approve
Do Not Approve

If Approve, Please Initial Below: *

I acknowledge that my pet is scheduled for an anesthetic procedure. I have been informed that advances in anesthesia and anesthetic monitoring techniques have made routine procedures relatively safe, with low rates of complications. However, I understand that occasionally problems can occur due to pre-existing conditions that are not evident during routine histories and physical examinations. I understand that some risk always exists with anesthesia, even in apparently healthy animals, including the possibility of death. I have discussed my concerns with the veterinarian and understand that it may be necessary to provide additional medical or surgical treatment to my pet in the event of unforeseen circumstances. I realize that no guarantee, legal or ethical, can be made to me regarding the outcome of any procedure performed. I hereby authorize the use of anesthetics and other medications, as well as any such additional treatment, as deemed necessary by the veterinarian. I understand that hospital personnel will be employed in treating my pet. I have carefully read, and fully understand, this consent. The fees associated with these services have been explained to me, and I agree to pay such fees at the time my pet is released from the hospital. (copy) *

I have read and agree

To minimize problems the doctors and staff at Chester Valley Veterinary Hospital have recommended that my pet be screened prior to anesthesia. *

I consent to the recommended pre-anesthetic diagnostics
I decline to the above recommended pre-anesthetic diagnostic test and in the absence of negligence, agree to hold the attending doctor(s) and staff at Chester Valley harmless for any untoward anesthetic, surgical, or medical complications that might have been detected and avoided had these tests been performed

Has your pet had any medications today? *

Yes
No

Has your pet had any food or treats in the past 12 hours? *

Yes
No

I hereby certify that I am the owner or authorized agent of the above-named animal and have the authority to execute this consent. *

I have read and certify

If your pet is aggressive or reactive to people and/or other animals please keep them in your vehicle until you have checked in and your technician is ready to bring you and your pet directly into an exam room.

Digital signature *

Date *