Anesthesia Dental Consent Anesthesia Dental Consent Pet's Name* First Last Date MM slash DD slash YYYY SpeciesAgeSexWeightPhone 1*Phone 2Owner Name First Last When did your pet last eat?* Is your pet coughing, sneezing, vomiting or having diarrhea? If yes, please provide details* What medications is your pet receiving at home?* Has your pet been scratching, itching or scooting?* Please choose and sign one of the 3 options belowChoose one of the options below and sign.I authorize the doctor to perform any and all extractions that are medically necessary, regardless of cost.I authorize an additional amount in case my pet needs extractions.I would like the Doctor to call me with an estimate.If you selected "I authorize an additional amount in case my pet needs extractions." Please select the amount you are willing to authorize up to. $550 $900 $1300 I certify that I am the legal owner/duly authorized agent for the owner of the animal described above, and do herby authorize Murphy Avenue Pet Clinic to provide care and perform treatment up-to and including diagnostic bloodwork, x-rays, vaccines, medications and administration of medical procedures they consider reasonable and necessary for my animal’s health, safety and comfort. I understand that with any medical procedure there are always risks involved, including death, and that no warranty or guarantee is being made as to the results or cure. I understand additional charges will accrue if my animal is not picked up before the hospital closes on the day he or she is ready to be released from the hospital. I understand payment in full is expected at the time of pick up and I assume full responsibility for all fees associated with the veterinary services provided.I understand every effort will be made to contact me and if I am unreachable my pet’s services may not be performed/completed in their entirety which could result in repeat visits and additional fees.Owner SignatureOwner Type Name CAPTCHA
