Name First Last Phone Number* Mailing Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Pet InformationPet InformationNameBreedDate of BirthColorSexSurgery Date:Type of procedure your pet is booked in for: Disclaimers: All pets must be fasted from food 12 hours prior to surgery admission and 1 hr for water. All pets found to have external parasites such as fleas will have a mandatory treatment applied and you are responsible for the cost of the treatment and decontamination. Prairie Animal Health Centre recommends all pets be vaccinated against Rabies; it is not mandatory but encouraged as it is a risk in our area to all pets regardless of lifestyle. Consent: Please select one of the following options for each question, leaving it blank is not an option. If unsure a staff member will discuss your options further.Have you read the fasting instructions? Yes No Have you read the external parasite disclaimer? Yes No Has your pet been well for the past 3 days? Yes No Is your pet in heat today? Yes No When was your pet’s last heat? Could your pet be pregnant? Yes No NA Unsure Has your pet been vaccinated for Rabies? Yes No If yes, provide name of the clinic that administered the vaccine and date it was administered on: If No would you like your pet vaccinated today? Yes No NA Unsure Does your pet have additional vaccines? Yes No If yes, bring proof of vaccination on the day of surgery. For pets vaccinated at PAHC proof of vaccination is not required. Pre-Anesthetic bloodwork is offered to all surgery patients prior to surgery. Pre-anesthetic bloodwork helps to determine the health status of your pet during anesthesia and provides a base line normal for the future. Bloodwork helps to determine if your pet has underlying conditions such as infection, anemia, inflammation, dehydration, underlying organ impairment such as kidney and liver insufficiencies that prevent or delay the body’s processing of anesthetic drugs. Bloodwork can help to reduce anesthetic risk by identifying health issues prior to the anesthesia and allow the staff and doctors to make the necessary adjustments to your pet’s anesthesia protocols to make it safer. Bloodwork does have an increased cost for pet owners and is not mandatory for elective procedures. Would you like a staff member to call and discuss the benefits and cost of pre-anesthetic bloodwork?* Yes No If No, you accept the risk to administer anesthesia without pre-anesthetic bloodwork.* Yes No We try and clip all pet’s nails under anesthesia at no charge. Would you like us to clip your pet’s nails during their procedure?* Yes No Would you like a microchip (permanent identification) inserted during your pet’s anesthesia?* Yes No Is your pet experiencing any signs of ear health issues such as itchiness or discharge?* Yes No Do you have any additional concerns that you would like addressed while your pet is under anesthesia? If so please write in the box below.Would you like an estimate prior to the procedure?* Yes No Your pet will be examined for umbilical hernias, retained deciduous teeth, hind dewclaws, and presence of testicles in males and signs of heat in females prior to surgery. Clients will be notified of abnormal exam findings prior to their treatment. Dogs in heat may have their procedure postponed to reduce their surgical complication risk. Pets that are mature or obese and female giant breed will have an additional fee applied for the increased surgery time and additional suture material. Important Please Read Carefully The safety of anesthesia has increased substantially with safer anesthetic drugs and increased knowledge of the effect of anesthetic drugs on different body systems. Despite these advances, general anesthesia is never trivial or routine and has risks such as death. I authorize the use of such anesthetics and medications as determined to be necessary for the above mentioned procedures. The risks associated with anesthesia and surgery has been explained to me. I understand that results cannot be guaranteed. A surgical risk also exists and varies with each procedure. Those risks include but are not limited to bleeding, pre-mature suture rupture, infection and swelling. The risk associated with surgery has been explained to me for the procedure my animal is having. I have read and understand this authorization and consent. Date* MM slash DD slash YYYY Contact Name* Phone*Alternate Phone*PhoneThis field is for validation purposes and should be left unchanged.