|
Southwind Animal Hospital, PLC
7910 Winchester Road
Memphis, TN 38125
Name: ______________________________________________ Date:
_________________
Pet's Name: __________________________________________ Time:
_________________
Authorization for Professional Services
Services to be performed today:
1. ___________________________________ 3.
_______________________________________
2. ___________________________________ 4.
_______________________________________
Doctor requested: [ ] Greenfield [ ] Moseley
[ ] Gebhart-Hooker [ ] Barnes [ ] Chandler
While your pet is here, would you like any of the following services
performed?
[ ] Heartworm Test [ ] ID
Microchip
[ ] FeLV/FIV Test
[ ] None
[ ] Vaccinations: ____________________________________
[ ] Other: ___________________________________________
In order to insure the safety and comfort of your pet during surgery or
dentistry, the following services are routinely performed (at the
veterinarians discretion):
· Pre-anesthetic laboratory evaluation
· Intravenous (IV) fluids and catheter
· Patient monitoring during surgery
· Pain medication
Current Medications:
____________________________________________________________
Medication last given: ______________
Diet: _____________________________
Has pet been fasted? ____________________
Contact information:
Phone where you can be reached today: _________________ Ask for:
_____________________
Consent:
I hereby authorize Southwind Animal Hospital to perform such diagnostic,
therapeutic and surgical procedures as are, in their opinion, necessary and
advisable for treatment and maintenance of my pet’s health and well being.
The nature of such services has been described to me to my satisfaction and,
while I expect all procedures to be done to the best of the abilities of the
professional staff, I realize that no guarantee or warranty can ethically or
professionally be made regarding the results or cure.
I also authorize the hospital director and staff to provide veterinary
service as required or in emergency circumstances to follow through with
such procedures as are necessary for the well being of my pet on a
continuing basic until further advised in writing.
I understand that I assume financial responsibility for all services
rendered.
Signature ___________________________________________________
Date _________________
Client/Pet Info verified [ ] VA/Tech ____ Requested
discharge time: _________ Call when ready [ ]
|