Mr.
Mrs.
Ms.
Dr.

Owner Name *

Best Way to Contact You? *

Cell
Home
Work
Text

Contact Number *

Would you like to opt in to receive text messages from Case Veterinary Hospital? *

Yes
No

Email *

Please be advised that we may need to reach you by phone while your pet is sedated or under anesthesia. We strongly urge you to be readily available in order to address unforeseen issues in the timeliest manner. If we are unable to reach you, our ability to complete your pet's procedure the same day may be compromised. For this reason, we will not text while your pet is in their procedure and will reserve text messages for communication prior to getting started or once recovered.

Pet Name *

Procedure to be performed: *

To minimize the risks associated with anesthesia and sedation, preliminary lab work is patient dependent prior to anesthesia or sedation. This preliminary information allows us to create the safest drug protocol tailored to your individual pets' needs. If your pet has not had lab work, we may still obtain samples the morning of their procedure. Associated costs, if applicable, will be added to your treatment plan. Please note that lab results may indicate a need for additional testing. Same day options are as follows:

Health Screen: Includes a Hematocrit (to assess anemia), Total Protein (to assess liver and kidney function), and BUN (to assess kidney function and hydration status). Recommended for junior patients. $46.50

Complete Blood Count (CBC) & Biochemical Profile: A complete count of blood cells and Hemoglobin in addition to electrolytes, kidney and liver function to better assess hydration status, anemia, infection, and immune system response. Recommended for adult and senior patients. $209.50

For an additional charge, I would like the following performed on my pet, while he/she is sedated:

Home Again Microchip Placement with 1-year registration: $58.50
Minor Ear Cleaning with Flush: $21.60
Nail Trim: $21.60

Deciduous (Baby) Teeth Removal:

As part of your pet's anesthesia check-in, one of our technicians will perform a brief oral exam to look for retained deciduous (baby) teeth. It is recommended that if present, they be removed, and the surgeon will contact you to discuss any additional cost.

There ARE deciduous teeth present
There are NOT deciduous teeth present

Below, you will find a Medical Intervention Release form. If you have filled this out recently, you may skip this part. If you have not filled this out before or would like to make updates, please do so at this time. This is a boarding requirement. Lastly, if you have multiple pets and the same applies to all, please list all their names. If the same answers do not apply to all, please specify in your comments.

Medical Intervention Release

Client Name *

First

Last

Pet Name *

Email *

Phone *

Would you like to opt in to receive text messages from Case Veterinary Hospital? *

Yes
No

It is our pleasure to spend time with your loved ones while you are away from home and thank you for trusting us to care for your family.

If medical intervention becomes necessary during your pets’ stay with us, every attempt will be made to contact you at the emergency number you have provided.

However, if we cannot reach you, we respectfully request that you provide us with the following instructions:

Do you authorize an examination and treatment to be performed at Case Veterinary Hospital? *

Yes
No

If an examination and treatment is authorized, what amount would you not want us to exceed?

In the event of a critical emergency, do you authorize transfer to Savannah Veterinary Emergency Clinic (SVEC)? *

Yes
No

If you have entered yes, you agree to be financially responsible for all treatment and services they perform. SVEC is not affiliated with Case Veterinary Hospital, and Case Veterinary Hospital is not responsible for payment.

Should your pet require life-saving measures, such as Cardiopulmonary Resuscitation (CPR), would you like for the Case Vet team to resuscitate or do you prefer that we do not resuscitate? *

Resuscitate
Do not resuscitate

*CPR authorization includes associated fees.

Do you decline any interventional care and associated costs? *

Yes
No

If you are declining, would you like to discuss alternative options for boarding? *

Yes
No

I authorize the performance of diagnostic procedures and use of anesthetic/ sedation agents as deemed necessary for my pet. I understand that preliminary lab work does not eliminate the risk of surgical, anesthetic, sedation complications, or even death, which may be currently unforeseeable. I acknowledge that the procedures have been explained to me and I fully understand the risks associated with anesthesia, sedation, and surgery. In the event of an emergency, I authorize Case Veterinary Hospital to provide lifesaving care.

Signature *

Date *

Authorization over Phone: *

Yes
No

Surgery/Anesthetic Release

Surgery/Anesthetic Release Form

Medical Intervention Release

It is our pleasure to spend time with your loved ones while you are away from home and thank you for trusting us to care for your family.

Your preferred Savannah veterinary hospital.

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