Boarding Consent Form

*Required Fields

*Owners Name:

Today's Date:

*Pet's Name:

Pick-Up Date:

Accomodations:

List Any Additional Services Needed (Vaccinations, Grooming, Bathing, etc.):

Medications (List each medication and dosage. Let us know if your pet has had today’s dose.):

There is an additional charge of $2.95 to $4.95 for each administration.

Diet and Instructions:

There is an additional charge for prescription diet.

Items (Limit 2):

We are not responsible for items left behind.

*All pets must be up to date on all vaccinations. If vaccinations cannot be verified, the pet will be vaccinated upon admission.

*Any pets with fleas and/or ticks at the time of admission will be treated at the owner’s expense.

I HAVE READ AND UNDERSTAND THE ABOVE. IF MY PET BECOMES SICK WHILE BOARDING I GIVE MEMPHIS ANIMAL CLINIC PERMISSION TO ADMINISTER THE NECESSARY TREATMENT AT MY EXPENSE.

*Signature:

*Date:

Emergency Number:

Name:

Surgical / Anesthesia Consent Form

*Required Fields

*Owners Name:

*Contact phone#

*Pet's Name:

I am the owner or agent for the above-described animal and have the authority to execute this consent. I hereby consent and authorize the performance of the following procedure(s) or operation(s):

I understand that during the performance of the foregoing procedures, unseen conditions may be revealed that may necessitate additional treatment. I authorize such treatment and procedures as are necessary and desirable in the exercise of the veterinarian’s professional judgment. I also release Memphis Animal Clinic from any liability concerning this procedure. I have been advised as to the risks involved in this procedure and that the results cannot be guaranteed.

IF FLEAS ARE SEEN ON YOUR PET WE RESERVE THE RIGHT TO PROTECT OTHER PATIENTS IN OUR FACILITY. IF FLEAS ARE NOTICED WE WILL APPLY THE NECESSARY FLEA PREVENTION TO YOUR PET AND IT WILL BE ADDED TO THE TOTAL COST OF THE BILL.

Pre-Anesthetic Blood Testing
We would like to inform you as the owner of this animal that hidden medical problems may manifest themselves by the stress of surgery. These medical problems may not always be obvious to the owner or the veterinarian. We advise a minimum database of presurgical blood work to ensure the safest anesthetic procedure possible for your pet. The cost is $49.95 for testing performed at the clinic immediately prior to anesthesia. These include hematocrit, total protein, BUN, ALT, CREA, and blood glucose.

YES, I want my pet to have presurgical blood workNO, I do not want my pet to have presurgical blood work

More thorough blood and urine tests are highly recommended for geriatric or chronically ill patients. These tests can be performed by an outside laboratory. It will take one additional day for these tests to be performed. Your pet’s elective surgery can be rescheduled if you decide that you too would like to be as safe as possible and have these tests performed. The additional charges for these tests would be $ 104.95. If you would like these additional tests, discuss your decision with the doctor.

Intravenous Fluids
Intravenous fluids given during anesthesia and/or surgery help to maintain blood pressure and allow rapid administration of drugs should an emergency situation develop. If blood pressure drops during the anesthesia it is more difficult to then place an IV catheter and valuable time may be lost which can result in the death of your pet. In the case of geriatric or chronically ill patients, catheter placement and fluids will be required and you will be informed of this prior to surgery

YES, I want an IV catheter placed prior to surgery, the cost is $29.95YES, I want an IV catheter and fluids used; the cost is $55.90NO, I do not want an IV catheter and fluids used

Microchipping Service:
Microchips are used as a permanent ID for your pet. If your pet were to ever get lost this would aid in their return home. We use the Home Again microchip system and while your pet is under anesthesia is an ideal time to place it. The microchip costs $49.95 with registration if they are under anesthesia. Additional registration fees apply through Home Again. Please initial if you would like us to place this today.

YES, I want my pet micro chipped.

E-Collar Consent:
It is hospital policy that all pets with an incision are discharged with an e-collar to protect the pet from chewing or licking the surgical site. Serious complications (i.e. dehiscence) may arise if a pet licks or chews apart an incision. We are able to provide your pet with an e-collar upon discharge and it will be yours to keep.

YES, I want to purchase an e-collar from MAC. The cost is $12.95. NO, I already own or will purchase my own e-collar and accept full responsibility for my pet.

Post-Surgical Consent:
We would like to inform you that there may be some degree of pain involved in this surgical procedure. We recommend that your pet receive an injection for the pain.

YES, I want my pet medicated for post-surgical pain. The cost is $34.95 to $38.95 depending on the animal’s weight.

YES, I want my DOG to receive pain medication for home. The cost is $16.95 to $24.95 depending on the DOG’S weight.

YES, I want my CAT to receive pain medication for home. The cost is $9.95 to $19.95 depending on the need for home meds as determined by the veterinarian. Kidney enzymes may be required to check at $19.95.

NO, I decline this service for my pet.

In Case of Emergency
Emergency telephone number where I may be reached:

I authorize the doctor, his/her agents or staff in an emergency situation to follow through with such procedures as are necessary for the well being of my pet on a continuing basis regardless of the additional cost which I understand cannot be estimated or calculated at this time. I understand that I assume all financial responsibility for all services rendered and for the cost of any inventory utilized during this emergency procedure.

I DECLINE any emergency treatment if complications develop during the above procedure.

It is understood that if any estimate is given to the owner/agent by the doctor, his/her agents, servants, and/or representatives to the owner/agent of owner that this is only an estimated price for the service rendered. It is understood that there may be unforeseen complications and that further treatment may be necessary for your pet during or following the above described surgical procedure.

The owner/agent of owner acknowledges, accepts and assumes full and total financial responsibility for any and all services rendered by Memphis Animal Clinic, its staff or employees in the treatment of the above described animal and to pay for such services when the services are performed or when the animal is picked up.

*Signature:

*Date:

I have read and received the Post-Surgical Discharge instructions.

*Signature:

*Date:

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