Date

Name *

First

Last

Owner Address

Address Line 1

Address Line 2

City

State

Zip Code

Owner Home Number

Owner Mobile Number

Owner Work Number

Pet’s Name

Species

Age

Sex

M
F
Spayed/Neutered

I, BEING RESPONSIBLE FOR THE ABOVE DESCRIBED ANIMAL, HAVE THE AUTHORITY TO GRANT YOU MY CONSENT TO RECEIVE, PRESCRIBE FOR, TREAT, AND/OR OPERATE ON MY PET.I UNDERSTAND THE SURGERY OR TREATMENT CONTEMPLATED IS:

Periodontal Treatment (COHAT)

Blood chemistry tests give us an inside look at your pet’s vital organs and let us know if they are functioning normally. Such tests are especially important before any kind of surgery. Our laboratory is fully equipped and staffed to perform these important tests.Results will be available immediately to review before anesthesia. An aging pet’s organs will gradually deteriorate, and may lose their ability to function properly. Routine preventative testing for early detection allows us to help your pet livea longer, healthier, happier life. These tests give us a look at your pet’s overall health status, from liver function to cholesterol levels:

Comprehensive Panel/Complete Blood Count(12 chemistry panel-ALKP, ALT, BUN, CRE, GLU, TP, AMY, PHOS, Na+, K+, TBIL, GLOB) Assure proper liver & kidney function as well as minor electrolytes/general blood cell health/count

IV Catheter/ Fluids

Because we monitor the blood pressure during all anesthesia procedures, we would like to insert an IV catheter and administer fluids. This enables us to maintain good blood pressure levels throughout the procedure. We may need to remove hair on a small portion of your pet's leg.

REASONABLE PRECAUTION WILL BE USED AGAINST INJURY, ESCAPE, OR DEATH OF YOUR PET. THE CLINIC AND STAFF WILL NOT BE HELD LIABLE FOR PROBLEMS THAT DEVELOP PROVIDED REASONABLE CARE AND PRECAUTIONS ARE FOLLOWED. I UNDERSTAND ANY PROBLEM THAT DEVELOPS WITH MY PET WILL BE TREATED AS DEEMED BEST BY THE STAFF AND VETERINARIAN(S) AND I ASSUME FULL RESPONSIBILITY FOR THE TREATMENT AND EXPENSE INVOLVED. I AGREE TO PAY FOR SERVICES RENDERED AT THE TIME THEY ARE COMPLETED. I WILL BE HELD RESPONSIBLE FOR REASONABLE COSTS INCURRED ON COLLECTION OF SAID FEES, SHOULD SUCH ACTION BE NECESSARY.

Signature

Clear Signature

Please indicate if your pet needs any vaccinations:

Canine Vaccinations

DHLPP
Rabies
Bordetella
Canine Influenza

Feline Vaccinations

FVRCP/FeLV
FVRCP
Rabies

My pet has had the following medications in the last week

COHAT Consent Form