Diagnostic/Surgical Consent Form Diagnostic/Surgical Consent Form Owner's Name * Owner's Name First First Last Last Date * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Email * Home Phone * Work Phone Cell Phone Phone where you can be reached today * Pet's name * Breed * Color * Age * Sex * Weight * “Our hospital policy is that we treat your pet as if it were our own” Has this pet received any food or water since 9:00 pm last night? * Yes No If yes, please inform the receptionist. Is this pet currently on any medications? * Yes No If yes, please list Has this pet ever bitten, scratched, or shown aggression toward anyone in any situation? * Yes No If yes, please explain Preferred Pet Food * Dry Canned What brand of food do you feed your pet? * How much? I understand the procedure I am consenting to is (select all procedures that apply) * Declaw 2 Feet, Front Declaw 2 Feet, Rear (declaws performed with laser) Declaw All 4 Feet Ovariohysterectomy (Spay) Castration (Neuter) Hernia Repair mass/wart/cyst removal Ultrasound (abdominal) Ultrasound (cardiac) Blood Test Radiograph OtherOther Mass/wart/cyst removal Quantity * Location * I understand the explanation you have given to me of the nature and purpose of the treatment, the risks involved, and the possibility of complications. I acknowledge that no guarantee has been made to me as a result of this procedure. PAYMENT IN FULL AT THE TIME OF DISCHARGE IS EXPECTED If any pet is not claimed within several days after the time specified for discharge and if the doctor is not notified in writing of an alternate date within the seven day period, the pet will be considered abandoned and become the property of Limerick Veterinary Hospital. LVH will decide what is in the best interest of the pet and its future. Abandonment of any pet does not relieve the owner/responsible party from any bill that may have been incurred for services/procedures performed on the pet after admittance to the point of abandonment. Should it be necessary to assign this account to a licensed collection agency or attorney, the owner/responsible party agrees to pay all subsequent collection and/or legal fees. I, being responsible for the above described animal, have the authority to grant you my consent to receive, prescribe for, treat and operate upon my pet. Owner/Responsible Party * signature keyboard Clear Date * If you are human, leave this field blank. Next