"*" indicates required fields

Has any of your information changed?*

Yes

This includes home address, phone number, email address, co-owner, etc

Information to be Changed

Co-Owner Name

Phone

Address

Street Address

Address Line 2

City

State

ZIP Code

Client Information

Client First Name*

Client Last Name*

Co-Owner First Name

Co-Owner Last Name

Phone*

Email*

Pet Information

Pet's Name*

Species*

Cat

Dog

Breed*

Sex*

Male

Neutered Male

Female

Spayed Female

DOB / Age*

Estimate if needed

Current Medications / Supplements

Name*

Dose*

Frequency given*

When last given*

Any refills needed?*

I am the owner, authorized agent for the owner, or a Good Samaritan responsible for seeking veterinary care for the animal described above, and I have the authority to execute this consent. My signature below certifies that I am over eighteen years of age.

I have been informed that there are certain risks and potential complications associated with sedation, anesthesia and/or any operation/procedure/treatment/medication that may result in injury, harm or even death from both known and unknown causes. These risks and potential complications have been explained to me to my satisfaction. I further understand that during the course of the operation(s) or procedure(s), unforeseen conditions may arise that may require the performance of additional urgent care services deemed necessary by the attending veterinarian. I am encouraged to discuss any concerns I have about these risks with the attending veterinarian before the procedure is initiated.

I authorize the use of appropriate anesthesia/sedation, hospitalization, diagnostic testing, patient monitoring, treatments and medications as needed before, during or after the procedure.

I understand that a treatment plan providing the details and costs for the anticipated veterinary services will be provided to me, and that I am encouraged to discuss all fees attendant to such care before services are rendered and during my pet’s ongoing medical treatment.

I further agree, that either I, or an authorized agent of mine will promptly pick-up and pay for all accrued charges when I have been notified that my pet is ready to be released from the hospital. I agree that if I fail to comply with this policy within five days of oral or written notification of the readiness to be released, that Companion Lake Zurich may handle this abandonment in the best interests of the pet and/or the hospital in accordance with the local laws and I will still be responsible for all fees incurred.

The nature of these operation(s) and/or procedure(s) has been explained to me to my satisfaction and I understand what will be done. I am aware that the practice of veterinary medicine is not an exact science and I understand that no warranty or guarantee has been either expressed or implied as to a cure or a specific result. I have been encouraged and given the opportunity to discuss any questions I may have regarding my pet’s medical care and my questions have been answered to my satisfaction. I accept that my financial obligations remain regardless of the outcome.

I have read and understand this authorization and hereby accept and agree to the terms of the consent for treatment.

Scheduled Treatment Date*

Unanticipated Dental Needs Plan

During the dental procedure detailed information about your pet’s oral health is made available from the in-depth oral exam and/or intra-oral x-rays that are only possible while your pet is under anesthesia. Due to this fact, during the procedure it may be determined that your pet’s dental disease and/or treatment needs may be more severe than originally anticipated. In the event that your pet’s dental treatment needs are materially different than originally planned, the hospital will make every reasonable effort to contact you at the emergency contact numbers provided during the procedure. However due to the need to limit procedure time, cost and anesthesia risk, if I am unable to be reached promptly, then the hospital staff must decide whether we perform the necessary oral surgery/additional treatments today while your pet is still under anesthesia if the attending veterinarian feels this is appropriate. Staging of the dental disease/oral surgery into multiple procedures may be required to best manage your pet’s comfort and anesthesia risk. Once your pet has recovered from anesthesia they will not be able to be put back under anesthesia on the same day.*

YES, I consent to any necessary oral surgery/dental extractions being performed today while my pet in in the hospital under anesthesia.

No, I do not wish to have any unanticipated dental treatment needs addressed without my explicit approval. I understand that if I am unable to be reached in a prompt manner during the procedure that the veterinarian will then move to end the procedure once the planned services are completed and wake up my pet from anesthesia. At that point, I will be required to schedule a second procedure at a later date in order to fully address my pet’s dental/oral disease.

If you approve to proceed with the necessary oral surgery/additional treatments, how much financially do you approve to cover those treatments?*

Emergency Care Plan

In the event that my pet requires emergency care during the stay, I understand that the hospital will make every reasonable effort to contact me at the emergency contact numbers provided. However, if I am unable to be reached prior to the time when the performance of the necessary care is deemed to be required by the attending veterinarian, the hospital’s staff has my permission to provide any necessary medical care for my pet.

CPR – In the event that your pet should experience cardiac or respiratory arrest while being hospitalized, do you give consent for resuscitative efforts to be initiated until you can be contacted further and notified of his/her status? By consenting to this service, you are also acknowledging that certain fees will apply. If you are not able to be contacted immediately, resuscitation efforts will be continued to be performed at the doctor’s discretion. Please select your choice below.*

I agree to CPR being performed in case of arrest

I elect a “Do Not Resuscitate” status in case of arrest

In the event that my pet requires emergency care during the stay, I understand that the hospital will make every reasonable effort to contact you at the emergency contact numbers provided. However, if I am unable to be reached prior to the time when the performance of the necessary care is deemed to be required by the attending veterinarian, the hospital’s staff has my permission to provide such medical care for my pet up to following amount:*

$200

$700

$2000

Other

If other, please specify*

Elective Procedures During Stay (additional charges apply)*

Please provide at-home dental care products for my pet

Please microchip my pet

Please clean my pet’s ears

Please express my pet’s anal glands

Please refill my pet’s Heartworm prevention

Please refill my pet’s Flea/Tick prevention

None of the above

Other

If other, please specify*

Primary Contact First Name*

Primary Contact Last Name*

Preferred Phone Contact Number*

Signature*

Date*

Name

This field is for validation purposes and should be left unchanged.

Dental Assessment/Treatment Consent

Information to be Changed

Client Information

Pet Information

Current Medications / Supplements

Unanticipated Dental Needs Plan

Emergency Care Plan

What's Next

Call us or schedule an appointment online.

Meet with a doctor for an initial exam.

Put a plan together for your pet.

Where family pets find loving care