Please enable JavaScript in your browser to complete this form.Client Name *FirstLastEmail *Patient Name *Phone number at which owner can be reached today or tomorrow: *SMS/Text MessagingI AgreeBy providing my phone number, I consent to receive SMS text messages from Robertson County Animal Clinic, for appointment reminders, marketing messages, and general two-way communication. Msg frequency varies. Msg&data rates may apply. Reply HELP for support. Reply STOP to opt out. For more information you can view our Privacy Policy.Additional numberBefore Procedure:Would you like to be contacted before your pet goes in for the procedure? *YesNoWould you like to be contacted by text or phone call before the procedure? *TextCallEitherIf text, at what number would you like to be texted?After procedure:Would you like us to text you after the procedure, or would you prefer a call? *TextCallAnesthetic and surgical procedure(s) to be performed: *I, the undersigned owner or agent of the pet identified above, authorize the staff of Robertson County Animal Clinic to perform the above procedure(s). *I have read and agreeMicrochip: *There is an additional fee for this procedure* *YesNoAlready has oneNail Trim: Would you like a complimentary nail trim for your pet? *YesNoHave you given your pets any medications or supplements in the past week? *Yes, pre-surgical packYes, other medication(s) (please specify below)NoOther medication(s), please specify and note last time givenWhen was the last time fed? Any other concerns/allergies/procedures?I understand that some risks always exist with anesthesia and/ or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. *I have read and agreeI am over 18 and understand that the attending veterinarian will make every effort to contact me regarding treatment in the case of unforeseen emergencies. If unable to contact me, the staff may or may not have my permission to proceed with life-sustaining procedures. *I give my permission [yes]I do not give my permission [no]While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow-up radiographs, re-check physical exams, and additional surgery due to postoperative complications. These are more likely to occur when there is a failure to comply with the aftercare instructions. I have been provided an estimated cost for the procedure(s) listed above. I assume financial responsibility for the recommended services and will provide payment in full at the time my pet is discharged from the hospital. I have read and fully understand the terms and conditions set forth above. *I have read and agreeSignature * Clear Signature Date *PhoneSubmit
