"*" indicates required fields Step 1 of 2 50% PhoneThis field is for validation purposes and should be left unchanged.Date* MM slash DD slash YYYY Client’s Name* First Last Pet’s Name*Contact Number*I certify that I own the animal named above. I consent and authorize Montgomery Animal Hospital and its staff to hospitalize my pet and to administer whatever sedation, tests, surgical procedures, treatments, medications and vaccinations that the doctors deem necessary for the health, safety and well-being of my pet while it is under their supervision. I understand that some pets may be required to stay overnight following the surgery either because of the nature of their surgical procedure or because of their failure to adequately recover from the anesthesia, and that there may be a fee for such overnight stays. If my pet should injure itself in an escape attempt, refuse to eat, soil itself, become ill or die while in the hospital, I agree not to hold Montgomery Animal Hospital and/or its staff responsible and/or liable in the absence of gross negligence. I agree not to hold Montgomery Animal Hospital and its staff responsible for complications caused by my pet’s postoperative overactivity, scratching, chewing or rubbing at his/her’s surgical site. If repairs for such activities are required, I agree to pay for all costs needed to repair any selfinflicted postoperative damage. I further agree that I am responsible to pay in full for the listed procedures/treatments at the time my pet is discharged. If I fail to pick up my pet within five (5) days of receiving written notice mailed to my address on record, Montgomery Animal Hospital may consider my pet to have been “abandoned” by me. The hospital then has my permission to dispose of my pet as it sees fit. I understand that “abandonment” does not release me from my obligation to pay my pet’s bill including any extra costs incurred due to my “abandonment.” I further agree that in the case of nonpayment of my pet’s bill, a finance charge of 1-1/2% per month (18% per annum) will be charged on the unpaid balance, and that the finance charge and any collection fees incurred by Montgomery Animal Hospital will be paid by me. PROCEDURE*When was the last time you pet was given any food item (i.e., meal, snack, biscuit)?*Signature*Date* MM slash DD slash YYYY What Number can you be reached while you are away?* Owners of animals 8 years of age and older are required to have PREANESTHETIC BLOODWORK performed on their pet prior to any procedure involving anesthesia. However, PREANESTHETIC BLOODWORK is optional for owners of animals who are under 8 years old. Preanesthetic bloodwork would reveal any underlying liver and/or kidney abnormalities which can be seen in young pets that might cause problems with anesthesia. If the blood test results are abnormal, the doctor may elect to change the type of anesthetic drugs selected for your pet in order to minimize anesthetic complications. The price for the recommended bloodwork is $115.00. (Bloodwork is REQUIRED in animals over 8 years of age).* YES, I understand that bloodwork is required for my pet at an additional cost of $115.00. YES, please perform the bloodwork for the $115.00 additional cost NO, I do not wish to have bloodwork performed Bloodwork Acknowledgement*InitialAll owners have the option of having a DATAMARS MICROCHIP placed under their pet's skin for identification purposes. Shelters and veterinary hospitals routinely scan for these chips when presented with a lost animal. The microchip can be placed when the animal is not anesthetized but, because a rather large needle is used, we recommend placing it while the animal is asleep. The discounted cost for the microchip when done at the time of surgery or dentistry is $58.00. The lifelong registration fee is included in this price. Initial below:* YES, please place the microchip at surgery NO, I do not want a microchip placed Microchip acknowledgement*Initial All dog owners have the option of having a hip x-ray taken of their dog while under anesthesia. This is especially recommended in dogs that will be over 50 lbs. when fully grown. The hip x-ray looks for any evidence of hip dysplasia which is an indicator for future arthritis. The discounted cost for a hip x-ray when done at the time of surgery or dentistry is $90.00. Please initial below:* YES, please take a hip x-ray NO, I do not want a hip x-ray Hip X-Ray Acknowledgement*Medications*NameDosageAmount/FrequencyLast Given (Time/Date) Add RemoveBelongings*ItemItem Description (Color, Size) Add RemoveI agree to be available for a phone consult should the doctor need to discuss additional extractions. I understand that if I cannot be reached Montgomery Animal Hospital will proceed with the recommended extractions/treatments at my expense. Phone number you can be reached*Signature*Date* MM slash DD slash YYYY
