Admit/Surgery Authorization Form"*" indicates required fieldsName* First Last Date* MM slash DD slash YYYY Phone*Client #Patient*BreedIs this BEST number? If not, Please Write in:Please NOTE if you prefer to be Called or Texted Call TextI, certify that I am the owner or responsible party of the above-described patient, being assessed/treated today. I have the authority to execute this consent. I am over the age of 18. I hereby authorize the DVM of MSVC, PC and the facility's authorized staff or agents consent to perform said procedures.*Client Initial herePLEASE NOTE BUDGET HEREProcedures* Exam Follow Up Ears Skin Joint Urine Combo Test Study Eyes Allergy XRays Microchip HW Test Fecal Da2PPL Lepto Bordetella Influenza Cortisol Thyroid Rabies FVRCP Leukemia Cadi Inj Sick Panel Blood Work Glucose Depo Inj Librela Inj Proheart Inj Day Board Bath Solensia Inj Zycortal Inj HWTX Flea RX Nail Trim Brush Out Anal Gland Oral HWPAdditionalI understand that during the performance of the examination, etc today that risks and potential complications involved have been explained to me. I understand what will be done and understand that additional procedures may be necessary and will be at additional fee.Initial here!***Should medical complications arise requiring emergency treatment and the veterinarian/staff is unable to reach me by immediate phone call, the dvm/staff at MSVC has permission to provide such treatment and I agree to pay for such care which may include emergency treatment and procedures up to*$ - Please NoteInitial here!*If CPR is necessary, do you want performed? Yes NoInitial here!*Signature*Date* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
