SURGERY ADMISSION FORM – URGENT CARE Step 1 of 4 25% Owner's Name(Required) First Last Phone(Required)Secondary PhoneEmail(Required) Followed up with text or phone call?(Required) Check In Date MM slash DD slash YYYY Pet's Name(Required) Species(Required) Pre-Surgery QuestionsWhat problems, if any, should the Doctor be aware of today?Did your pet eat this morning? Is your pet on any medication? If so, what kind, how often, and did your pet take any this morning? OWNER CONSENTThe medical and surgical treatment required for my pet has been described and explained to me. I consent and authorize Vet Partners, their respective owners, agents, and employees to receive, sedate, treat and/or operate on my pet as directed below. I understand that many pets require sedation before a thorough oral examination can be completed. The condition of each tooth must be evaluated before a decision is made as to the best course of treatment. Sometimes it is impossible to give an accurate estimate as to the cost of extraction before sedation. I understand that completing all needed dental procedures during the initial visit and sedation rather than is more economical for my pet. Accordingly:Please perform whatever procedures & extractions are required at this time.(Required)Please SelectI agreeI DO NOT agreePlease perform whatever procedures & extractions are required up to $_________(Required) I consent to the above amount I designated without additional authorization:(Required)Please SelectI agreeI DO NOT agreeProceed without authorization?(Required)Please SelectYes, please proceed without additional authorizationNo, please call for authorizationPlease call me after the exam with an estimate of any additional procedures that are needed.(Required)Please SelectYes, please call meNo call is neccessaryIn addition to the treatment my pet receives today, other care may be required, especially, but not solely, in the presence of an emergency. I authorize Vet Partners, their agents and employees to conduct additional treatments and operations, tests, or injections that may be, in the judgment of Vet Partners or any employees of the clinic, considered advisable or necessary at the time the contemplated treatment or operation is being performed. OWNER RELEASEI understand that sedation, anesthesia, and all medical treatment involves risk to my pet. Vet Partners, their respective owners, agents, and employees use all reasonable precaution against injury. Vet Partners and their respective owners, agents, and employees shall not be held liable in any manner or under any circumstances in connection with any injury, escape, or death of my pet as a result of the treatment my pet receives. I hereby release, forever discharge, and hold harmless the foregoing parties from any claim based on such treatment or other medical services. I have read, understood, and agree to the foregoing. I understand that by signing this form I am waiving valuable legal rights.Credit Card Transaction Fees(Required) I understand there is a 3% fee for credit card transactions Owner's Signature (Digital)(Required) Date(Required) MM slash DD slash YYYY In case of an emergency, please call:(Required) Relationship:(Required)