"*" indicates required fields To ensure the utmost safety and comfort of your pet, we perform a pre-operative blood panel, place an IV catheter for fluid therapy 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, herby authorize Hancock Park Veterinary Clinic to perform the following procedure, which will require anesthesia or sedation. Procedure* Name* First Last Pet Name* Do you have our phone app ?* Yes No If no, please download as moving forward we are going to do our best to ensure we are communicating through the app. If yes, please ensure your notifications are on to ensure you are receiving our updates throughout the day. Would you like any additional treatments? Microchip $82.03 Anal Gland Expression Retained deciduous (baby) teeth removal Other Other Procedure* Address for MC registration Risks/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 Hancock Park Veterinary Clinic:* I DO want any/all measures performed to save my pet. I do NOT want heroic measures taken to save my pet. Heroic measures may include oxygen treatment, iv fluids, additional medications, and CPR. Additional fees of at least $150 will be charged if this is necessary. Fees/Payment-It is understood that I shall be responsible for the costs in connection with any care and/or medical treatment resulting from any ensuing complications related to the above procedure and that payment shall be made in full, prior to the return of my pet to my care. I understand that any fees given for elective surgeries or procedures are only estimates. ***To ensure complete anesthetic recovery, plan to pick up your pet AFTER 4 pm. *** We will call you after your pets procedure to give you a more precise pick-up window. Has your pet had anything to eat past midnight?* Yes No If yes, what did they eat and what time? Phone Number to best reach you*Pick up time for surgery is usually between 3:30-4:30 pm, does that work for you?* Hours : Minutes AM PM AM/PM By signing below I acknowledge that I have read and agreed to the information in this form. Date* MM slash DD slash YYYY Time* Hours : Minutes AM PM AM/PM Signature*
