Pet Owner's Full Name *

First

Last

Owner's Email *

Pet’s Name Undergoing Procedure *

Date of Scheduled Procedure or Surgery *

Our Top Priority For Your Pet's Procedure Is To Keep Them

SAFE & HAPPY

We use state-of-the-art equipment and prioritize educating our clients, so you know the appropriate aftercare for your pet.

What is Pre-Anesthetic Bloodwork?

Pre-Anesthetic Bloodwork consists of a CBC, Chemistry, and Coag Panel. These bloodwork panels will check important values such as kidney and liver enzymes, glucose levels, blood cells, and clotting times. These blood panels help your pet's veterinarian assess the health status of your pet more completely, allowing your pet's veterinarian to take additional precautions that may be necessary to maintain the health and safety of your pet while under anesthesia.

These pre-anesthetic bloodwork panels are REQUIRED for all patients over the age of 7 years, NO EXCEPTIONS. For all patients under the age of 7 years, the pre-anesthetic bloodwork is optional, but highly recommended.

Would you like your pet to have pre-anesthetic bloodwork completed prior to their procedure? *

I Do
I Do Not

What is Cerenia?

Cerenia is an anti-nausea medication that helps greatly on reducing post procedure nausea / vomiting. This medication is a requirement for all surgical procedures.

It is the Hospital's Policy to give a Cerenia Injection prior to all surgical procedures. Please type "I Understand" below to acknowledge this medication requirement. *

Why Place an IV Catheter?

An IV Catheter will allow immediate vein access if needed in case of an emergency during a procedure. An IV Catheter also allows for easier sedation protocols for patients.

It is the Hospital's Policy to place an IV Catheter for all surgical procedures, regardless of the patient's age or pre-existing health conditions. Please type "I Understand" in the box below to acknowledge the requirement of IV Catheters. *

What is a Pet Microchip?

It is a very small device that will aid veterinary professionals, health officials, and pet owners in identifying pets in case they are found far away from their regular surroundings. This device cannot be used to track your pet, but to identify them in the event they are lost.

Do you wish your pet to be microchip, for a one time fee of $30.00. *

I Do
I Do Not

Courtesy Nail Trim

Should you like your pet's nails trimmed while under anesthesia, our team would be happy to do so at no cost to you. In the event you would like to your pet's nails dremeled, the cost will be discounted to $15.

Would you like your pet to receive a courtesy nail trim? *

Yes, I would like my pet's nails trimmed.
Yes, I would like my pet's nails dremeled at the additional cost.
No, I would not like my pet's nails trimmed.

What is Laser Therapy?

Laser Therapy stimulates tissue regeneration, promotes cell growth, and decreases the amount of healing time your pet may need after their surgical procedure. The use of Laser Therapy is not recommended for all procedures and is at the discretion of your pet's veterinarian. In the event it is advised by your pet's veterinarian for laser therapy to be completed following their procedure, there will be a nominal fee added to your invoice.

It is the Hospital's Policy to complete Laser Therapy on all applicable patients. Please type "I Understand" in the box below to acknowledge this requirement. *

Patient Medications:

Is your pet currently taking any medications, or has taken any medications in the last 30 days? *

In the Event of a Life-Threatening Emergency:

I understand that during my pet's procedure, unforeseen circumstances may arise. In the event any unforeseen circumstances result in life-threatening conditions for your pet, with your permission, our team can administer life-saving measures, such as: emergency drugs, oxygen therapy, and CPR.

By authorizing life-saving measures for your pet, you are hereby consenting to our veterinarians to use their professional judgment to act and/or react to these unforeseen circumstances, which may incur additional fees at your expense.

I understand that I will be financially responsible for all emergency procedure expense costs and that our staff is not required to contact you with an estimate of costs prior to administering life-saving measures if prior authorization is selected. I hereby authorize the staff of Northwood Animal Hospital "NAH" to render any treatment that is deemed necessary to the health of my pet(s) while in the custody of the hospital. I understand that in the event of any unusual or emergency circumstances, the staff will make a reasonable attempt to contact me before, if time permits, proceeding with the treatment.

In the event of a life-threatening emergency: *

I authorize veterinary staff to perform life-saving measures.
I DO NOT authorize veterinary staff to perform life-saving measures.

ACKNOWLEDGEMENT AND SIGNATURE

I accept that all procedures will be performed to the best of the abilities of the staff at this facility. I understand that veterinary medicine is not an exact science and that no guarantees have been made regarding the outcome of my pet's procedure.

I understand that a deposit is required for this procedure and that certain Policies and Fees apply to such. In the event you do not show up for your pet's procedure as scheduled and without notice, all previously paid deposits will be taken as a "No Show Fee," and a new $100 deposit must be paid prior to rescheduling.

If you need to reschedule your pet's procedure more than 2 weeks prior to the originally scheduled date, your deposit will be rolled over to the reschedule date. If the procedure is rescheduled less than 2 weeks in advance to the originally scheduled date, an additional $50 rescheduling deposit will be required. This deposit will add onto your initial $100 deposit and will be applied towards your total at checkout on the day of your pet's procedure. If you arrive more than 15 minutes late, your pet's procedure could be rescheduled, resulting in the $50 rescheduling deposit.

I understand that full payment is expected at the time of my pet's discharge, and agree to provide payment in full via cash, personal check, credit card, Scratchpay, or CareCredit. I understand that failing to be financially responsible with my Northwood Animal Hospital account could result in my Northwood Animal Hospital account being sent to a third-party collection agency, which may affect my credit rating.

I have read and agree to the statements above: *

Yes, I have read the statements above
Yes, I agree to the statements above

(Check all of the boxes above)

Today's Date *

Phone Number(s) Where Pet Owner(s) Can Be Reached Immediately: *

Email(s) Where Pet Owner(s) Can Be Reached Today: *

(List as many as applicable, carefully check for typos, and using the following format: Order in which to be contacted, complete and error free email address, name of the person being emailed. *List each email separately*)

Name of Authorized Alternative Decision Maker: *

Phone# of Authorized Alternative Decision Maker: *

Electronic Signature of Owner/Authorized Agent *

Clear Signature

By Electronically Signing Above, You Are Agreeing to the Terms & Conditions of this Form.

Please do not submit any Protected Health Information (PHI).

Online Form

Anesthetic Consent for Medical Procedures and Surgeries Form