I hereby entrust Beaverton Pet Clinic (BPC) to care for my pet during his/her surgery stay. I am the owner, or a representative of the owner, of the animal presented and have the authority to execute this consent. I have been advised as to the nature of the procedure to be performed and the risks involved. I understand the doctors and staff will use all reasonable precaution against the injury and/or death of my pet, and I hereby consent and authorize this hospital to perform the requested anesthesia and surgical procedures. In the event of unforeseen complications, I give permission to the doctors and staff to take reasonable measures in treating my pet and accept all charges that are incurred as a result of such action. I understand that I must furnish phone number(s) where BPC can reach me or a contact person whom I have authorized to make medical decisions. *

I have read and understand.

ADDITIONAL TREATMENT DIRECTIVE

Procedures requiring anesthesia are time-sensitive and provide a narrow window of time in which to reach you. For your pet's safety, please list where you or your agent can be reached without delay. *

I have read and understand.

Patient Name *

First

Last

Name of contact person: *

First

Last

This person is: *

Owner
Authorized Agent

Phone Number *

In the event you or your authorized contact person are not reachable, would you prefer us to proceed with any additional recommended treatment? Please select your preference: *

Yes, please proceed with additional treatment. I understand that there will be additional charges for further treatments.
No, please do not proceed with any treatment beyond the initial treatment plan, unless my pet's safety requires it.

E-mail *

Telephone is our primary means of contacting you regarding your pet's procedure, however we sometimes email updated estimates, forms, home care instructions, etc.

BLOOD TESTING

Blood testing is required within the last 2 months for pets 7 years or older, and within the last 6 months for pets under 7 years of age. I understand that blood work is an important aid in determining my pet's health, but does not guarantee a more successful surgery. *If bloodwork is not current, it will be required prior to surgery at an additional fee* *

I have read and understand.

FEMALE DOGS BEING SPAYED ONLY - HEAT CYCLE - What are the approximate dates of your dog's last heat cycle (beginning-end)?

Beginning of Heat

End

PICKUP AFTER SURGERY

Standard pickup time is usually between 2:00-5:30 pm. We will do our best to accommodate your requested pickup time but due to the nature of hospital operations and anesthesia recovery this may not always be possible. Please provide the earliest and latest times you are able to pick up your pet. *

I have read and understand.

Earliest Time: *

(the earliest available time is 2:00 pm)

Latest Time: *

(the latest available time is 5:30 pm)

Do you have Pet Insurance? *

Yes
No

If yes, do you plan on submitting the final invoice for insurance reimbursement?

Yes
No

I understand that the safety of my pet is the overriding priority. I understand that any price quote I have been given is an estimate and if complications are involved, or the procedure is of greater dimensions than anticipated, the price may be higher. I understand that by signing below, I agree to pay for all charges incurred as such and will pay the balance in full upon discharge of my pet. *

I have read and understand.

Printed Name *

Today's Date *

PRE-ANESTHESIA QUESTIONNAIRE
Please complete no later than 7am on the procedure date

I have been informed of the fasting requirements for anesthesia and will not/have not fed by pet since 11pm the night before surgery: *

Yes
No - if selected, please contact us immediately at 503-646-6101
Other

If Other, please explain *

Is your pet on any medications? *

Yes
No

If yes, please list name of medication(s) and when the last dose was given:

Have you recently applied or given a flea medication to your pet? *

Yes
No

*If your pet is found to have fleas we will administer flea treatment at a cost of $10

If yes, what date:

Has your pet been ill recently? If so, please describe the symptoms and indicate date/time of last symptoms: *

Does your pet have an ID Microchip? *

Yes
No

If no, would you like us to implant a microchip today while your pet is under anesthesia? (Cost: $53)

Do you have any other questions or concerns for the doctor?

Are there any additional services you would like us to perform while your pet is in the hospital (charges may apply)?

Anesthesia Release – General Surgery