Date of procedure

Owner's full name *

First

Last

Pet's name *

Species

Dog
Cat
Ferret
Other

Vaccinations

Vaccinations must be current to stay in the hospital. If your pet has been vaccinated elsewhere, please either bring a copy of the records (or receipt) or upload a copy to us prior to your pet's visit. I verify that my pet has had a Rabies vaccination and Upper Respiratory/Distemper vaccination within the last 1-3 years

VACCINATIONS

Yes
My pet was vaccinated elsewhere
No. Please vaccinate my pet today

Proof of vaccinations from another location

External Parasite Protection

Pets found to have fleas or ticks upon presentation will be treated and charged accordingly ($15.00 for pets under 25#, $25.00 for pets over 25#)

Pre-Anesthetic Bloodwork

Pre-Anesthetic Bloodwork appropriate to your pet's age and health status has been performed or will be performed prior to giving any medications.

For Cats Only

Feline Leukemia/ Feline Immunosuppressive Virus Testing is recommended annually for roaming outdoor cats, sick cats, or cats with gingivitis/ stomatitis.

Checkboxes *

Yes, Please ($135.00)
No, thank you

Anesthesia I authorize the use of appropriate anesthetics and other medications. I understand that during this procedure(s), unforeseen conditions may be revealed that necessitate an extension of the same or different procedure(s) than set forth above. I also understand that, despite pre-surgical exams and diagnostics, unforseen conditions may exist that may cause unexpected anesthetic complications. I authorize the Doctors and Staff to do everything within their power to prevent anesthetic complications.

Resuscitative directive

In the unlikely event of Cardiac Arrest, I authorize the following:

Checkboxes (copy) *

CPR (If I am not reachable within 15 minutes, I understand that CPR efforts will be discontinued if spontaneous breathing has not been recovered. I agree to pay all costs incurred in resuscitation.
Do Not Resuscitate and please assist humane euthanasia.

Other services

I would also like the following procedures performed

Checkboxes (copy)

Toenail Trim ($19.00)
Anal Sac Expression ($35.00)
Microchip/ Registration ($78.90)
Bath (40# and under: $38.50, Over 40.1# and up: $60.50))
Brush out ($20 up)

Contact information

It is CRITICAL that we have contact information so that you can be reached throughout the day in case of Emergency or the Doctor needing to discuss your pet's condition. Preferred Method of Communication Today:

Contact information

Phone call
Text
Email

Phone

Alternate Phone

Text Number

Email *

Anything Else? Notes to your Cimarron Team?

$ Treatment plan *

I have signed a $Treatment Plan for the cost of the procedures indicated in this Document
I have not signed a $Treamtment Plan, please contact me.

By Typing my Name Below *

I have been advised as to the nature of the procedure(s) and the risks involved. I understand that my pet may be shaved in multiple locations for both the procedures identified above as well as for an IV catheter. I realize that results cannot be guaranteed but understand that the Doctors and staff will, in good faith, perform procedures to the best of their ability to prevent complications. I agree to pay for all services rendered at the time of my pet's discharge regardless of outcome.

Name *

First

Last

Date Signed

Surgical / Anesthesia Consent Form

Vaccinations

External Parasite Protection

Pre-Anesthetic Bloodwork

For Cats Only

Resuscitative directive

Other services

Contact information

By Typing my Name Below *

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