Animal Hospital of Lake Villa • Consent Form

Name *

First

Last

Email *

What phone number will you be available at should we need to discuss your pets procedure today? *

For quality and training purposes all phone calls are recorded.

This number needs to be answered if we call. Failure to answer our call may result in the inability to finish your pets procedure. If your pet is anesthetized, we will only keep them asleep for about 10 minutes while we wait for a call back. At the end of the 10 minutes, we will have to wake up your pet. *

I understand the above statement.

Pet's Name *

Pet Species? *

Canine
Feline
Other

IF Other, Please List Species Below *

What Procedure Is Your Pet Here For? *

I, the undersigned, do hereby certify that I am the owner (or duly authorized agent for the owner) of the animal described above, that I do hereby give Animal Hospital of Lake Villa, its agents, and/or representatives, full and complete authority to perform the surgical/medical procedure discussed. I further consent to the performance of operations and procedures in addition to or different from those now contemplated, arising from presently unforeseen conditions, which the veterinarians or their associates or assistants may consider necessary or advisable in the course of the operation. I further consent to the administration of such anesthetics as may be considered necessary or advisable by the veterinarian responsible for this service. To minimize the risk of such occurrences, we offer the following: Pre-surgical exam, Bloodwork, and monitoring the entire time they are here. As my signature below indicates, I understand the nature and purpose of the operation, possible alternative methods of treatment, the risks involved, and the possibility of complications, and I have no further questions. I recognize that the practice of medicine and surgery is not an exact science and acknowledge that no guarantees or assurances have been given to me as to the result of any treatment, medication or procedure given at the hospital. With all dentistries, we include full-mouth radiographs. Most lesions are 30% below the gum line and are not visible to the eye. These radiographs will be done before the cleaning so we can take extra care of the teeth that need to be extracted. This price is included in your estimate.

If, Other, Please Explain. *

Please confirm the procedure discussed with your veterinarian.

Would you like us to perform a screening radiograph of your pets hips today? *

Yes, I would like a screening of my pet's hips.
No, I would not like a screening of my pet's hips.

This will help us evaluate the condition of their hips and may potentially help us find problems, such as Hip Dysplasia. Finding such problems now can help us bring relief options to your pet much sooner.

Stem Cell Banking Questions

Would You Like to Know More About Stem Cell Banking Through Gallant?* *

Yes
No

*Stem cell banking can offer peace of mind by investing in the health of your pet. This is best done during spaying or neutering procedures. Additional charges apply.

For more information on stem cell banking, visit lakevillavet.com/gallant/

Orthopedic Exam Questions

Which Leg or Paw is Affected? *

Front left
Front right
Back left
Back right

Approximately When Did the Limping Start? *

Was There an Accident or Any Known Trauma to the Leg? *

Yes
No
Unsure

If Yes, Please Explain *

Can Your Pet Run? *

Yes
No

Can Your Pet Jump? *

Yes
No

Can Your Pet Play? *

Yes
No

Difficulties Going Up or Down Stairs? *

Yes
No

When Does the Limping Get Worse? *

After resting or laying down
After exercise
Constantly limping

Check all that apply.

Does the Limping Improve After Some Activity or Exercise? *

Yes
No

Has this Limping Happened Before? *

Yes
No

If Yes, Please Explain *

Have You Noticed Anything Abnormal When Your Pet is Running? *

Yes
No

If Yes, Please Explain *

Dentistry Question(s)

Extractions *

Yes, I give consent to do what is needed.
Yes, I give consent to perform extraction up to the dollar amount stated below.
No, I do not give my consent for any extractions.

I understand that with the nature of dentistry, extractions can arise after the initial scaling of the teeth. I understand that the cost of extractions is not in the initial price of the dentistry unless stated. If my pet needs extractions I authorize Animal Hospital of Lake Villa to perform these extractions as selected above.

Dollar Amount Over Estimate? *

Mass Removal Questions

Are You Able to Upload Pictures of the Mass(es)?

Click or drag files to this area to upload. You can upload up to 10 files.

You can upload up to 10 files.

Please Describe the Mass Locations in as Much Detail as Possible! *

Front Left Paw, Abdomen, Tail, Head, etc.

Would You Like Us to Send the Mass Out for a Biopsy? *

Yes, I consent to biopsy.
No, I do not want to send it for biopsy.

General Questions

How is Your Pet's Food & Water Intake?

Does Your Pet Have Any of the Following Symptoms? *

Check all that apply.

How is Your Pet's Behavior at Home? *

Normal
Quiet/Lethargic
Other

If Other, Please Explain

Pre-Anesthetic Bloodwork Testing *

I understand bloodwork is mandatory before all surgical procedures unless done within the last two months.

Like you, our greatest concern is the well-being of your pet. Before putting your pet under anesthesia, we will perform a full physical examination. However, many conditions, including disorders of the liver, kidneys or blood, are not detected unless blood testing is performed. Such tests are especially important before any kind of surgery. For these reasons, we perform a mandatory blood screening before such procedures (unless previously done within the last two months in our clinic).

Shaving *

I understand that in order to provide the best possible patient monitoring and care that my pet may have a small area shaved on their chest and legs.

Microchip Identification Placement *

Yes, I would like a microchip inserted into my pet while he/she is in the hospital and/or under anesthesia. This includes one year of registration.
No, please do not microchip my pet.

Blankets - Does Your Pet Get Nervous & Chew Them? *

Yes
No

We will monitor your pet while they are here to make sure they don't chew blankets or towels.

Is Your Pet on Any Medications Currently? *

Yes
No

Do not skip giving your pet his or her medication. If giving it with a little a bit of food that is okay, just do not give your pet a full meal. Pets 30 lbs and up can have about an egg size amount of food, for pets under 30 lbs quarter sized meatball of food.

What Medication(s) *

Please list the medication(s) given.

Behavioral Intervention *

I understand that if my pet is experiencing fear, stress, or anxiety, that Animal Hospital of Lake Villa may administer a pharmaceutical to help calm the patient before the procedure takes place.

Pictures & Texting - May We Text You Status Updates & Pictures of Your Pet? *

Yes, please send status updates, including pictures.
Yes, please send status updates, however I don't need pictures.
No, I do not want to receive status updates or pictures.
Please, call with updates.

May We Use Pictures For Our Own Social Media? *

Yes
No

Is the Phone Number You Listed Above the Same Number You Want Text Messages Sent to? *

Yes
No

If No, Which Number Are We Texting? *

Payment Options *

The undersigned also understands that all services are to be paid in total when the pet(s) is/are discharged unless prior arrangements are made. The owner or agent promises to pay such total, together with any other charges, finance and/or collection, due thereon. A written estimate will be furnished upon request. Forms of payment accepted include Cash, Mastercard, Visa, American Express, Discover, Scratchpay, or Care Credit. Personal checks are not accepted as a form of payment.

Signature of Owner *

Date *

Consent For Procedure

Stem Cell Banking Questions

Orthopedic Exam Questions

Dentistry Question(s)

Mass Removal Questions

General Questions