Client Name:
Pet:
Breed:
Color:
Age:
Sex:
Weight:
Allergies:
Admitting Technician:
Has your pet had a meal within the last 8 hours?
Has your pet had any reactions to medications or vaccines?
Does your pet have any history of seizures?
Would your like your pet Micro-Chipped during today’s procedure?
***ALL PETS MUST BE CURRENT ON VACCINATIONS and TESTING***
(Exam, Distemper, Rabies, Biannual Bordetella, Biannual Fecal and Heartworm Testing)

I authorize St. Francis Pet Care Center to perform the following operations and/or treatments:

It has been explained to me that during the course of the operation unforeseen conditions may be revealed that necessitate an extension of the
original procedure or different procedures than those listed above. I therefore authorize and request St. Francis Pet Care Center to perform such
surgical procedures as are necessary and desirable in the exercise of professional judgment. I have also been informed that there are certain risks
and complications associated with any anesthesia, operation or procedure. These risks and complications have been explained to me as well. I
further understand that during the course of anesthesia, operations or procedures, that unforeseen conditions may arise that may necessitate the
performance of additional procedures. I understand these risks. I authorize St. Francis Pet Care Center to perform upon my pet the diagnostic
procedures above and the necessity of these procedures has been explained to me

In the treatment of my pet, procedures other than those listed above may become necessary.
I would like: (Choose One)
Financial Limit $:
I have been provided a written estimate:
I acknowledge the above and have authority to make the above decisions about my pet and accept the financial responsibility for services
rendered payable by me before my pet is released.
Type Name as Signature:
Date:
Please provide a phone number and/or email address
Owners Email:
Owners Phone:
Text Preferred?
Please indicate below where your pet has been injured: