Step 1 of 2 50% Date*Owner's Name*Cell Phone*Emergency Number*Pet's Name*Dog or Cat*DogCatBreed*Color*Sex*MaleFemaleAUTHORIZATION TO PROVIDE CARE FOR ELECTED PROCEDURE(S)* CASTRATION/NEUTER OVARIOHISTERECTOMY/SPAY TRANQUILIZATION/SEDATION DENTAL OTHER If other, please describeI (The Owner) or authorized agent of the owner of (The pet listed above), authorize and direct the veterinarians of Westwood Veterinary Clinic, and/or their assistants to perform the services described above and all procedures, diagnostic, treatment, and/or administration of medication within the accepted veterinary guidelines, as deemed advisable and/or necessary for my pet. Westwood Veterinary Clinic will take every responsibility and action to ensure the success of the procedure. I understand the possibility of death, as a severe complication of surgery, anesthesia, or any other procedure does exist. I am aware that these procedures are performed as a precaution; preliminary blood work, monitoring the pet while it is in surgery and providing nursing recovery care until pet goes home. I understand that the pet is to fast 10 hours prior to be anesthetized. There is no guarantee nor can one be made as to the results of any therapy. I understand that Westwood Veterinary Clinic may not be present overnight; only during office hours. If I neglect to pick up the pet within 7 days of above, you are to assume that the pet has been abandoned and you are authorized to dispose of the pet, as you deem best. A deposit may be necessary or all fees may be due upon release of patient. I fully understand the terms of this agreement and do authorize the hospital staff to perform the above indicated services on my pet. It is also agreed that if I do not pay this account as agreed, that past due accounts are subject to costs of collection, including attorney’s fees. Signature* CHEMISTRY PROFILE - CBC AND ELECTROCARDIOGRAMANESTHESIA CARRIES SOME RISKS (EVEN THOUGH IT MAY BE SMALL). THEREFORE ,BLOOD TESTING IS RECOMMENDED BEFORE GENERAL ANESTHESIA. LIVER AND KIDNEYS REMOVE THE ANESTHETIC AGENTS FROM THE BODY. SO IT IS IMPORTANT TO KNOW BEFORE ANESTHESIA IS ADMINISTRATED THAT THESE ORGANS ARE FUNCTIONING AT 100%, BLOOD WORK HELPS US MAKE THIS DETERMINATION. IF THERE IS ANY INDICATION OF DISFUNCTION, THEN APPROPRIATE STEPS CAN BE TAKEN TO ENSURE THE SAFETY OF YOUR PET. AS WELL, AN ELECTROCARDIOGRAM IS RECOMMENDED TO ENSURE THE WELL BEING OF YOUR PET. WE MAY HAVE ALREADY RECOMMENDED THESE PROCEDURES. IF NOT, YOU CAN ELECT THESE TESTS TO BE PERFORMED BY WRITING YOUR INITIALS IN THE APPROPRIATE BOXES BELOW. IF THERE IS ANY INDICATION OF ABNORMALITIES, OUR CLINIC WILL EITHER CONTACT YOU BEFORE PROCEEDING OR TAKE THE STEP NECESSARY TO HELP ENSURE THE SAFETY OF YOUR PETFEE FOR CHEMISTRY PROFILE ($67.00)*YES, I WANT MY PET TO HAVE A PRE-ANESTHETIC BLOOD SCREENING.NO, I DO NOT WANT A PRE-ANESTHETIC BLOOD SCREENING PERFORMED.FEE FOR CBC TEST ($38.00)*YES, I WANT MY PET TO HAVE A CBC TEST.NO, I DO NOT WANT A CBC TEST PERFORMED.FEE RADIOLOGY TWO VIEWS ($120.00)*YES, I WANT MY PET TO HAVE A RADIOLOGY STUDY.NO, I DO NOT WANT A RADIOLOGY STUDYFEE FOR ELECTROCARDIOGRAM ROUTINE TEST ($183.99)*YES, I WANT MY PET TO HAVE AN ELECTROCARDIOGRAM ROUTINE TESTNO, I DO NOT WANT AN ELECTROCARDIOGRAM TEST PERFORMEDFEE FOR PT/PTT TEST (COAGULATION PANEL) ($85.00)*YES, I WANT MY PET TO HAVE A PT/PTT TESTNO, I DO NOT WANT A PT/PTT TESTDate* Date Format: MM slash DD slash YYYY Signature*CAPTCHANameThis field is for validation purposes and should be left unchanged.