| DIAMOND VETERINARY ASSOCIATES |
| 3625 Rucker Avenue |
| Everett, WA 98201 |
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SERVICES CONSENT FORM |
| OWNER:____________________________ |
| ADMISSION DATE_____________ |
PICK-UP DATE ______________ |
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| Procedure_________________________________________________ |
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| NAME/NUMBER OF RESPONSIBLE PARTY TO BE REACHED IN CASE OF EMERGENCY: |
| ________________________________________________________ |
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Your pet is here today for anesthesia and/or surgery, and although your pet should do well, these procedures always carry some risk. We will perform a full physical examination on your pet before administering anesthesia. However, we HIGHLY RECOMMEND that a pre-anesthesia blood profile be performed prior to anesthesia to help rule out any pre-existing medical problems that may not be physically evident. There is an additional fee of $64.50 for this procedure. Our in-house laboratory allows us to run these blood chemistries within minutes.
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Please circle your choice:
- Please COMPLETE the blood work. If any abnormalities are found
please call and inform me at #_____________________
- I DECLINE the pre-anesthetic blood work at this time.
I request that you continue with the surgical procedure.
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| Please indicate (by circling) if you would like any additional services while your pet is under anethesia: |
| Microchip |
Express |
Anal Glands |
| Ear Cleaning |
Apply flea control |
Nail Trim (No charge) |
| Vaccinations____________ |
| Other___________________ |
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Please voice any concerns or questions regarding our services or your pets health. The best medical care is based on good communications between you and our staff. We are ready to assist you in any way we can.
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| Owner (or agent) signature authorizing above procedure: |
| Sign________________________________ |
Date_______________________ |
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| Admitting staff member______ |
