Date* MM slash DD slash YYYY Owner's name:* Patient's name:* Species* Sex*MaleFemalePhone (Primary)*Phone* Home Cell Work Phone (Secondary)Phone Home Cell Work Email* As the owner or agent of the owner of the above animal, I hereby give my consent to Norris Animal Hospital to perform the following procedures:List procedures:* Dental Extractions: I understand that during routine dental cleanings, it is sometimes necessary to perform routine/surgical extractions. I also understand that there is an additional fee for additional extractions(s).Routine Extractions* Yes, extract as needed No, call first to confirm Surgical Extractions* Yes, extract as needed No, call first to confirm Laboratory Tests Waiver If your pet is to be anesthetized, rest assure that advances in anesthesia and surgery have made procedures relatively safe with a low rate of complications. Nevertheless, occasional problems can arise due to pre-existing conditions not evident during routine preanesthesic examinations. To avoid these problems, we highly recommend that all surgical patients be screened before anesthesia by means of the following laboratory tests. Please select an option for each of the following:Preanesthetic Panel: Kidney & Liver Enzymes, Blood glucose, Total Protein, CBC, & Electrolytes* Approve Decline Feline Leukemia/FIV Test (Sent out the Antech Labs overnight)* Approve Decline Heartworm Occult Test* Approve Decline Intestinal Worm Check and Stool Analysis* Approve Decline Microchip Pet Identification* Approve Decline Signature (Name) of Owner/Agent:* Today's Date: MM slash DD slash YYYY
