Consent for Treatment - Southwoods Animal Hospital

Date of Upcoming Procedure:(Required)

Pet’s Name:(Required)

Owner’s Name:(Required)

First Last

What food do you currently feed, including regular treats:(Required)

How frequently and how much do you feed this pet?(Required)

What is your pet’s heartworm prevention medication and when was the most recent dose given?(Required)

What is your pet’s flea & tick prevention medication and when was the most recent dose given?(Required)

Is your pet on any additional medications or supplements on a regular basis?(Required)

Yes

If yes, please describe medication/supplement name, frequency of administration, and most recent dose:(Required)

ANESTHESIA EXPLANATION

The doctor, and/or you, the client, have determined that your pet requires sedation for this procedure. Any use of sedation or anesthesia carries inherent risks. The veterinary staff of Southwoods Animal Hospital will take utmost care to avoid any complications, but such complications cannot always be foreseen. Animals that require frequent sedation for procedures (such as grooming, bathing, etc.) may be required to have periodic blood screenings to confirm kidney and liver health. I understand the risks of sedation and will not hold Southwoods Animal Hospital responsible for unforeseen complications. I authorize Southwoods Animal Hospital and its veterinarians to perform sedation on my pet.

While 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 this/these procedures. I have read and understand the nature of the above procedures and accept the specific terms and conditions set forth herein.  

Should unexpected life-saving emergency care be required I would like the hospital staff to attempt life-saving measures:

I authorize Southwoods Animal Hospital to do whatever is necessary should an anesthetic complication arise, and I accept responsibility for any additional expenses incurred.(Required)

Yes

Vaccination Requirements:

I understand that my pet must be current on vaccinations for canines: DHPP, Bordetella, and Rabies (administered by a licensed veterinarian) and felines: FVRCP and Rabies (administered by a licensed veterinarian) to stay in this facility. If my pet is overdue for these vaccines or if I fail to provide proof of vaccination, they will be administered at my expense.

Initials(Required)

Fleas & Tick Policy:

I understand that if external parasites are found on my pet that an appropriate treatment will be administered at my expense.

Initials(Required)

SEDATION CONSENT

I, the undersigned owner, or owner's agent, of the pet identified above, certify that I am at least 18 years of age, and thereby consent to the examination and treatment of my pet by the veterinarians and staff at SWAH, and after consultation with me to prescribe medication for, treat, hospitalize, anesthetize.(Required)

Initials

While performing the sedated procedure, should the Dr. find the procedure(s) to be more involved resulting in additional cost, I will be contacted at the phone numbers listed below. If I cannot be contacted, I authorize the doctor to perform the necessary procedure(s).(Required)

Initials

I agree that I, or an agent of mine, will pick up my pet and pay for all accrued charges at the time my pet is discharged. Boarding and treatment charges will accrue for each additional day my pet stays in the facility. If I fail to pick up my pet from SWAH within 5 days of receiving written or oral notification given to the contact information on file that my pet is ready to be released, my pet will be considered as abandoned, and SWAH may handle this abandonment in the best interest of the animal and the hospital.

Best Contact Number:(Required)

Emergency Contact Number:(Required)

Name(Required)

First Last

Signature(Required)

Address:	3005 Randleman Road Greensboro, NC 27406 336-275-7266
E-mail:	info@southwoodsvet.com