Standard Consent Form Standard Consent Form Please indicate what type of general procedure your pet is having:* Wellness exam Blood Glucose Curve Hospitalization (IV fluids, patient monitoring, etc.) Shave Other Describe in detail how you would like your pet shaved/groomedHead*Body*Legs*Other*Other* Patient* Owner Name* First Last Appointment Date* MM slash DD slash YYYY Phone*Has your pet eaten today?* Yes No What time?* Is your pet urinating normally?* Yes No Is your pet defecating normally?* Yes No Has your pet vomited in the last 24 hours?* Yes No Is your pet currently on any medications?* Yes No What is the name of the medication your pet is on?* What time was the last dose given?* If an emergency arises please perform CPR and other life saving measures. By allowing the doctor(s) and staff at Crossroads Animal Hospital to perform CPR, there are additional charges for which I will be responsible. CPR for the first 15 minutes averages $150.* I accept I do not accept I am the owner/agent for described animal. I hereby authorize and request an exam for my pet. I also authorize and request treatment to be done for my pet today, if applicable. I understand that sedation and/or pain medication will be provided if deemed necessary. I understand Crossroads Animal Hospital will contact me after procedure(s) have been performed on my pet. I have an initial estimate of charges and understand that I will be responsible for any costs incurred. I understand that during the performance of this procedure, unforeseen conditions may be revealed that necessitate an extension or variance in the procedure(s) set forth above. I expect Crossroads Animal Hospital to use reasonable care and judgment in performing the procedure(s). I am also aware that unforeseen events resulting from the procedure(s) will not relieve me from any obligation to all costs incurred regarding the animal. All animals admitted must have a current rabies vaccination and be free of external parasites. Any animal found to have fleas, ticks, or to be unvaccinated against rabies will be treated at the owner’s expense. I also understand that if my pet is fed a special diet today during their visit I will be responsible to pay for the special diet.* I understand and agree to the terms mentioned above. Number to contact you today*Signature* Reset signature Signature locked. Reset to sign again Δ In
