Anesthesia, Surgical, & Medical Consent "*" indicates required fields Name* First Last Today your pet is scheduled for the following procedure:*Procedures most often require at least a 12 hour fast. When is the last time your pet ate?*While your pet is anesthetized, we will have a very unique opportunity to provide addition services to him/her. Please select additional service(s) you would like performed today:* Nail Trim (Complimentary) Anal Sac Expression ($36.00) Routine Ear Cleaning ($15.30) Microchip Placement ($48.90) Statement of Ownership and Treatment ConsentI certify that I am the owner, responsible agent, or authorized agent of the pet described below. I authorize the Doctor and staff of Forest Crossing Animal Hospital to perform the procedure and/or services described above, including the administration of sedative and/or anesthetics, as well as any necessary and appropriate medical, radiological, surgical, diagnostic, and/or emergency care for this pet. I have been advised as to the nature of the above described procedure, and fully understand the potential risk(s) associated. I also understand that there is no guarantee of successful treatment. Furthermore, I understand and agree that if my pet is abandoned at Forest Crossing Animal Hospital without prior arrangements being made, Forest Crossing Animal Hospital will contact me by certified mail at the address I have provided. I then have ten (10) days to retrieve my pet. If I have not made contact with Forest Crossing Animal Hospital on or before the tenth (10th) day, Forest Crossing Animal Hospital receives full ownership of my pet. I agree to pay in full for the services performed, including those deemed necessary for medical or surgical complications, or unforeseen circumstances. The estimate provided is based on the best information currently available and is not a guarantee of charges.If a staff member is able to stay past closing to accommodate a late pick up, a charge of $49.50 will be added to your account. If you have requested an after-hour pick up and are unable to get your pet by 6:30 a charge will be added to your account of $49.50 + a boarding fee that best accommodates the size of your pet.Phone number where you can DEFINITELY be reached*Secondary phone number where you can DEFINITELY be reachedSignature*CAPTCHA Δ