Surgery Authorization Please fill out this form as completely and accurately as possible. Get Started Hospital/Surgery Admittance and Authorization Form f you have any questions, please feel free to contact us at 775-329-4106. Surgery Authorization Form Name(Required) First Last Email(Required) Phone(Required)Please list all procedures that your pet is having done today.(Required)Please list any concerns that you have about the procedure your pet is having today.(Required)I certify that I am the owner of my pet and am over 18 years of age.(Required) I certify All pets entering the hospital must be free of internal and external parasites (fleas, ticks, roundworms, tapeworms, etc.) or they will be treated at the owner's expense.(Required) I have read and understand The hospital requires that your pet be current on vaccines prior to being admitted to the hospital. If I cannot provide proof of these vaccines, I understand they may be done while my pet is here, at my expense.(Required) I have read and understand I have received a verbal or written estimate on today's procedure(s) for my pet(s) visit to the hospital.(Required) I have read and understand I understand there is a hospitalization charge for all pets staying in the hospital for 1/2 or full day.(Required) I have read and understand I understand if my pet undergoes general anesthesia he/she will have an IV catheter placed and receive IV fluids during the procedure for his/her safety (with the exception of feline neuter).(Required) I have read and understand Fairgrounds Animal Hospital is not a 24-hour Hospital. We do NOT have a staff member at the hospital overnight. I understand that the continuous presence of personnel is not provided during nighttime hours or weekends. I have the option of taking my pet to The Animal Emergency Center if such care is deemed necessary. I understand and agree that if I do not come for my pet by 6 pm and he/she is not stable enough to stay at the hospital unattended overnight, he/she will be admitted to the Animal Emergency Center and treated at my expense.(Required) I have read and understand Please acknowledge the above items are true(Required) I certify that the above items are true LASER: A one-time photon laser healing therapy session is performed for post-operative incision care, treatment of inflamed tissues, and many other conditions involving pain, inflammation. I authorize the administration of oral medications, including controlled substances, to my pet if prescribed by my veterinarian. I understand these medications may be administered by a veterinary assistant.(Required) I accept I decline CPR: In the event that an emergency should arise, I give permission for the doctors/staff to perform/use lifesaving measures such as CPR. As in humans, cardiopulmonary resuscitation (CPR) is an emergency technique used when an animal has stopped breathing and has no heartbeat. It involves rescue breathing (mouth-to-snout resuscitation) and chest compressions. (Additional cost begins from $300.00 to $1000.00)(Required) I accept I decline Bloodwork: Please select one permission level(Required) Level 1: IV Catheter, endotracheal intubation (assisted breathing), Oxygen therapy, Rescue drugs, Chest compression (additional cost - begins from $300 - $1000) Level 2: is level 1, plus Open chest cardiac compressions. This Level of CPR is advanced and Pet would need to be transferred to 24 hour facility after stabilization for further treatment: $2000.00 - $7000.00 & Pet TRANSFERED TO EMERGENCY CENTER. I decline all CPR Pre-surgical bloodwork is strongly recommended by Dr. and may be required depending on your pet's age and/or health status. Pre-surgical bloodwork is required for all senior pets (over 7 years old). If bloodwork is optional, if bloodwork is declined, I understand and accept all potential risks involved. (Additional cost for bloodwork ranges between $200 to $300).(Required) I accept I decline Safeguarding our patients is our first priority. Including an ECG in preoperative diagnostic screening is one of the most cost-effective measures we can take to ensure patient's safety during anesthetic events. This ECG is an additional $87.20.(Required) I accept I decline If your pet is having a mass removed or biopsy done today, do you accept?(Required) I accept I decline My pet is not having a mass removed or biopsy done today. Additional Services You Would LikeWould you like any of the following services done while your pet is sedated or under anesthesia today?(Required) Teeth brushing = $9.05 ONLY general anesthesia/sedation I would like my pet to have a Homeagain microchip today = $60.60 (registration included) Anal glands expressed = $ 10.00 Oravet gel plaque prevention application = $14.05 ONLY general anesthesia/sedation Ear cleaning basic (0-5min) = $31.55 ONLY general anesthesia/sedation No additional services today Financial PoliciesPayment Method CareCredit Mastercard Visa Discover Debit Card Cash Check Pet Insurance Full payment is required at the time of pick up ***FOR ESTIMATES... Due to the nature of medicine, your total may be up to 15% higher than the high amount of your estimate.*** Every effort will be made to stay within the range of the estimate. Please initial hereIs your pet currently taking any medications? If yes, which medications? Has your pet had any complications with any medications or anesthesia? If so, please explain. Photo and/or Information Release for Media or Website PublicationAfter an explanation of its intended use, I authorize the staff at Fairgrounds Animal Hospital to release portions of my pet's photographs, video images, or other images to use with the following media entity(ies): Fairgrounds Animal Hospital website/brochures, social media platforms (Facebook, Twitter, Pinterest, Yelp, etc.), television, and in the print media. I understand that this information may be used for advertising and/or public education purposes. I, the undersigned, allow my and/or my pet's name to be used along with photographs, video, or other images of my pet. I, the undersigned, authorize this veterinary practice or institution's faculty, clinicians, employees, students, and/or agents to use such materials for the purpose of educating the public about my pet's condition and medical care. I agree not to file any claim for revenue or lawsuit for damages against this veterinary practice with respect to the release of this information. Please initial hereRelease Agreement/Terms and ConditionsI/we being the legal owner and at least 18 years of age hereby consent and authorize you to receive, prescribe for, treat, or operate upon the above-described animal(s) and any future pets registered. You are to use all reasonable precautions against injury, escape, or destruction of the animals(s), but you will not be held liable or responsible in any manner whatever, or any circumstances, on account of the care, treatment, or safekeeping of the animal(s) above described, or otherwise in connection herewith, as it is thoroughly understood that I/we assume all risks. I/we will assume full responsibility for all charges incurred in the care of the above-described animal(s). I/we also understand that these charges will be paid in full at the time of release with the knowledge that we do not offer billing. I/we also understand that a deposit may be required for certain surgical treatments or other procedures. Please initial hereAny animal left here for more than 10 days past the date of release or 10 days without contact from the owner will be considered abandoned and may be disposed of, or destroyed, as the hospital deems best. It is also understood that your doing so does not release me from paying all costs of your service and the use of your hospital, including the cost of boarding. I have read, understand, and agree to all of the above. I also understand that there is always risk associated with general anesthesia or sedation, and I have had an opportunity to discuss these risks with a doctor or staff member. Please initial hereEmergency Contact Name(Required) First Last Emergency Contact Phone(Required)CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.