Drop Off Consent Form Explore Drop Off Consent Form "*" indicates required fields Owner’s Name* First Last Co-Owner’s Name First Last Contact Phone Number*Secondary Phone NumberName of Animal*Species*I am the owner, or the agent for the owner of the above-described animal. I hereby authorize and give consent for the performance of the following procedures:* Xrays Surgery/Anesthesia Hospitalization Fluid Therapy Oxygen EKG/Vitals monitoring Observation Vaccinations/preventative care Diagnostics/work-up Clip/clean Wound care/bandaging Other Please specify*Has your pet had any medication in the last 24 hours?* Yes No What was given and when?*I understand the following additional procedures are optional, but highly recommended, please select below to authorize: Heartworm Test – canine Feline Leukemia/Feline Immunodeficiency Virus test Microchip/registration Due to unforeseen circumstances, if we find an issue that needs to be addressed during your pet’s stay, and we are UNABLE to get a hold of you (please select one option below): Perform only what services have been authorized on the estimate Perform additional services deemed necessary by the veterinarian Perform only services, up to the amount I specify $ amount*Your pet will be undergoing a procedure that may require sedation. All precautions will be taken to ensure the safety of your pet. However, there are always risks associated with sedation procedures, and although they are minimal they do exist.* I understand n the event of a life-threatening emergency, while your pet is with us, would you like us to perform CPR?* Accept Decline I have read the above information and understand its contents.* I have read and understand Payment is due when the patient is released.* I understand I give Sage Veterinary Care permission to post photos of my pet on Social Media (e.g., Facebook).* Accept Decline Signature*Date* MM slash DD slash YYYY CAPTCHA Δ
