| The Omro Animal Hospital Dr. Philip C. Johnson, D.V.M. Dr. Robert L. Wright, D.V.M. PAYMENT POLICY Payment is expected at the time of service for all routine services and elective surgery. We accept cash, checks, MasterCard, Visa, Discover, and American Express. We will also accept a check to be held for up to 30 days, the check must be dated the day of the service. A $2.00 service charge plus interest at the rate of 1.5% will be charged on all balances over 60 days. If I do not pay this account as agreed the past due account is subject to costs of collections, including attorney’s fees. AUTHORIZATION TO TREAT Due to the contagious nature of external parasites (fleas, ticks, mange, mites, etc.), any animals with these pre-existing conditions will be treated at the owner’s expense. The Omro Animal Hospital is to use all responsible precautions against injury, escape, or destruction of the animal(s), but The Omro Animal Hospital will not be held liable or responsible in any matter whatever, or any circumstances, on account of the care, treatment or safe keeping of the animal(s), as it is fully understood that I assume all risks. I fully understand the terms of this agreement and authorize the hospital team to perform the indicated services on my pet. ______________________________________________________________________________________________ ______________________________________________________________________________________________ I am the owner or authorized agent of the owner of the pet presented for care. I authorize the Doctor to administer pain relief medication after surgery to my pet if need be. □ I WOULD LIKE POST OPERATION PAIN MEDICATION TO GO HOME WITH MY PET. ALL DECLAW SURGERIES INCLUDE PAIN MEDICATION THAT GOES HOME WITH THE PET. PAIN MEDICATIONS COST BETWEEN $5.50-$16.50, DEPENDING UPON THE WEIGHT OF YOUR PET. □ I am declining post operation pain medications at this time. __________________________ ______ Owners Signature Date In case of an emergency or questions we may have for you regarding your pet, could we call you at work, and if so can we have the phone number. This phone number would be where we are able to reach you between 10am and noon. ________________________ Phone number Please make checks payable to The Omro Animal Hospital, Thank You!! |
The Omro Animal Hospital
Dr. Philip C. Johnson, D.V.M. Dr. Robert L. Wright, D.V.M.
Pre-Anesthetic Blood Testing Consent Form
__________ __________ ____ _________
Client Patient Age Date
PLEASE READ CAREFULLY AND SIGN
Like you, our greatest concern is the well being of your pet. Your pet is scheduled for anesthesia and/or
surgery. Before putting your pet under anesthetic, we recommend a pre-anesthetic blood profile to be
performed in order that we may maximize patient safety and alert the doctor to the presence of dehydration,
diabetes, and/or kidney or liver disease which could complicate the medical procedure. These conditions
may not be detected unless a pre-anesthetic profile is performed.
These tests are similar to those your own physician would run were you to undergo anesthesia. In addition,
the results of these tests may be useful later to develop faster, more accurate diagnosis and treatment in
the event that your pet’s health changes.
Our doctors recommend these tests for your pet. Cost $45.50
BUN (Kidney) ALT (Liver) RBC & WBC
(Red & White Blood Cell Counts)
CREATININE (Kidney) ALKP (Liver)
GLUCOSE (Blood Sugar) TOTAL PROTEIN (Hydration)
( ) Please complete the blood work you recommended prior to surgery on my pet. If any abnormalities are
found please contact me at this phone number.
__________________________ _______________________
Signature of Owner Phone number
( ) I have elected to refuse the recommended pre-anesthetic blood work at this time and request that you
proceed with anesthesia. I assume full financial responsibility for this/these animal(s). I understand there
are always potential risks when using anesthesia or performing surgery on an animal.
__________________________
Signature of Owner
Dr. Philip C. Johnson, D.V.M. Dr. Robert L. Wright, D.V.M.
Pre-Anesthetic Blood Testing Consent Form
__________ __________ ____ _________
Client Patient Age Date
PLEASE READ CAREFULLY AND SIGN
Like you, our greatest concern is the well being of your pet. Your pet is scheduled for anesthesia and/or
surgery. Before putting your pet under anesthetic, we recommend a pre-anesthetic blood profile to be
performed in order that we may maximize patient safety and alert the doctor to the presence of dehydration,
diabetes, and/or kidney or liver disease which could complicate the medical procedure. These conditions
may not be detected unless a pre-anesthetic profile is performed.
These tests are similar to those your own physician would run were you to undergo anesthesia. In addition,
the results of these tests may be useful later to develop faster, more accurate diagnosis and treatment in
the event that your pet’s health changes.
Our doctors recommend these tests for your pet. Cost $45.50
BUN (Kidney) ALT (Liver) RBC & WBC
(Red & White Blood Cell Counts)
CREATININE (Kidney) ALKP (Liver)
GLUCOSE (Blood Sugar) TOTAL PROTEIN (Hydration)
( ) Please complete the blood work you recommended prior to surgery on my pet. If any abnormalities are
found please contact me at this phone number.
__________________________ _______________________
Signature of Owner Phone number
( ) I have elected to refuse the recommended pre-anesthetic blood work at this time and request that you
proceed with anesthesia. I assume full financial responsibility for this/these animal(s). I understand there
are always potential risks when using anesthesia or performing surgery on an animal.
__________________________
Signature of Owner