Pet Last name Date

I authorize to receive, prescribe for, treat or sedate/anesthetize my pet. The nature of this treatment/procedure has been described to me to my satisfaction and while I expect all procedures to be done to the best ability of the professional staff. I realize no guarantee nor warranty can ethically or professionally be made regarding the results of the procedure. I also authorize the staff to provide emergency services as necessary should complications arise.

I understand that if I do not return for my pet written notice will be mailed to my address. Five days after written notice my pet will be considered abandoned and become the property of property of Pet Samaritan Clinic to do with as they deem best.

I realize that my pet will be discharged only during regular office hours and when the Dr. or their associates are present, and the fee due for its care will be paid in full at that time. I realize that in many cases it is impossible to determine in advance the extent of medical or surgical treatment required, but in such cases Pet Samaritan Clinic will attempt to estimate the cost of treatment.

It is understood that the actual cost my exceed or be lower than this estimate.

PRE-ANESTHETIC SCREENING & GAS ANESTHESIA

I have authorized the professional staff of Pet Samaritan Clinic to administer an anesthetic drug to my pet in conjunction with bathing. I understand the staff will take all precautions to ensure a successful outcome of the procedure including, but not limited to, a pre-anesthetic physical exam. ($46.00)

We recommend pre-anesthetic screening to detect any problems with major organ functions(i.e. liver and kidneys) that may not be physically evident but could contribute to serious complications during anesthesia. The cost is 85.75

DO YOU WANT A BLOOD SCREEN? YES NO PLEASE INITIAL:

We now have two types of anesthetic gas available. Isofurane is the standard we have used for many years and is considered to be quite safe. Sevoflurane is newer to the market and is considered to be the safest gas anesthetic available. We highly recommend Sevoflurane especially for ill or older animals.

The cost is $3.25 per minute for Isoflurane and $5.25 per minute for Sevoflurane.

PLEASE SELECT THE TYPE OF ANESTHETIC YOU WOULD LIKE: I want Isoflurane I want Sevoflurane Leave to doctors discretion

PLEASE INTIAL:

Lion cut prices are $96.75 - $120.75

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