*2021_Anesthesia/Procedure Consent Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Thank you for entrusting to us the health of your pet. We hope you and your family are staying safe and healthy.

Because of the safety precautions we have to implement in response to COVID-19, we request our clients to fill out this Form in advance. A part of our social distancing protocol is to primarily communicate with our clients by phone during the appointment. Your answers to the history form will further help us better understand what needs to be done with your pet as well as address other concerns that you may have.

We appreciate your kindness, patience, and cooperation.

Email *

Full Name of Client and Pet's Name *

Budget Threshold *

In this time of COVID-19, we want to let you know that we are mindful of our client's budget. While we attempt to provide an approximate cost of our services, an estimate can easily change because every veterinary patient is different, and the corresponding care varies. Certain surgical procedures can have unforeseen problems/complications that significantly impact the veterinary care provided and consequently the cost. Please indicate the dollar amount of your budget threshold below and we will call you once your budget threshold is reached or if about to go over.

Patient History *

Please write here ALL the pertinent information that you want Dr. Elmar Zamora to know about your pet relevant to this appointment.

Mode of Payment *

Credit/Debit Card - please prepare your Driver's License

Care Credit - please prepare 2 forms of ID (https://www.carecredit.com/apply/)

Scratchpay - (https://scratchpay.com/consumer?clinic_id=6308)

Check

Cash

Other:

Required

Consent to Anesthesia/Procedure/Blood Test (if applicable) *

I acknowledge there may be concealed health risks to my pet and release A.E.Z.R. PET HOSPITAL and staff from liability from any unforeseen complications arising from anesthesia/surgery. I hereby authorize the admitting veterinarian or designated associates and assistants to perform diagnostic tests/procedures on my pet, as applicable. I confirm that the doctor/staff explained the procedure thoroughly to me and how it will help my pet with its current condition. I understand the risk and complications if I do not follow the instructions given to me after the procedure which involves post-treatment and follow-ups. I understand that anesthetic and surgical, diagnostic, or therapeutic procedures may involve risk of complications, injury, or even death, from both known and unknown causes and no warranty or guarantee has been either expressed or implied as to result or cure.

I have read and I understand the statement above and release the doctors and staff of A.E.Z.R Pet Hospital from any liability.

PATIENT FASTING PROCEDURE: I will comply with the fasting pre-operative protocol required for my pet (no food or water at least 12 hours prior to the procedure)

PRE-ANESTHETIC LAB TEST: Approved (a test to screen for health conditions that might impact the anesthetic procedure. This could require a separate appointment for the blood draw - additional fees apply)

I DECLINE the Pre-Anesthetic Lab Test

This consent is valid for ONE YEAR from date signed

This consent is valid for this procedure only

I have read and I DECLINE the procedure/surgery/treatment plan for my pet.

Other:

Required

CHECK-IN Client Health Disclosure *

If you are sick, or have fever, body aches, cough, etc., please have a family member or a friend bring in your pet.

I do not have fever, coughing, and body aches for the past 14 days

I have not been diagnosed with COVID-19; I am not being treated for COVID-19 nor was treated for COVID-19; I am not in self-quarantine because of COVID-19

I have not been exposed to someone confirmed with COVID-19

I have not travelled outside of California for the past 14 days

I have travelled outside of California but it was more than 14 days ago

I was diagnosed with COVID-19 but have recovered (please indicate the date of diagnosis and the date when cleared as negative in "Other" below)

Required

Signature / Date Signed *

By typing my full name below, it constitutes my acknowledgment that I have provided information to the best of my knowledge.

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of A.E.Z.R. Pet Hospital. Report Abuse

Forms