To ensure the utmost safety and comfort of your pet, we perform a pre-operative blood panel, place an IV catheter for fluid thearpy and to allow medication administration and give full pain medications with all of our anesthetic procedures. Patients are also fully monitored with state of the art equipment and trained nursing staff while under anesthesia. I, the owner or agent of the animal identified below, hereby authorize Hancock Park Veterinary Clinic to perform the following procedure, which will require anesthesia or sedation. Procedure* Spay/Neuter Dental under Anesthesia Local Mass removal Mass removal under anesthesia Other Procedure if other*Name* First Last Phone Number to best reach you*Pet Name*Vehicle Make/Model/color*Do you have the HPVC app? Our app is best way to ensure you are able to see all communications and pet reminders. It also allows requesting appointments, medications, and medical records.*YesNoRisks/Complications - I acknowledge that there are certain risks to any anesthetic/sedation/surgical procedure including but not limited to post-operative bleeding, infection, bloat, and death. I also acknowledge that there is an increase risk of bleeding in pregnant, in heat, or obese females and that there may be an additional charge for these conditions at the surgeon's discretion. I understand the inherent risks of anesthesia and release Hancock Park Veterianry Clinic, doctors, and staff of any liability.If in the unlikely event that life saving measures need to be taken while my pet is under the care of HPVC*I DO want any/all measure performed to save my petI do NOT want heroic measures taken to save my petHeroic measures may include oxygen treatment, IV fluids, addition medications, and/or CPR. Additional fees of at least $150 will be charged if this is necessary. Again, in the unlikely event these measures are need, we will contact you as soon as the pet is stable.What time are you available to pick up your pet today? Expect pick-up no later than 4:30pm, closing time.* : HH MM AM PM Date* Date Format: MM slash DD slash YYYY Time* : HH MM AM PM Would you like any additional treatments? Microchip $75.06 (MICROCHIPID) Anal Gland Expressio Retained deciduous (baby) teeth removal Other Other Procedure*Signature*