1 Start 2 Complete Have you been in contact with someone who has tested positive for COVID or had COVID symptoms? * Yes No Have you traveled in the past 14 days? * Yes No Have you or anyone in your household felt sick with COVID like symptoms in the past 14 days? * Yes No Owner's Name (first and last) * Email Address * Phone Number * Pet's Name * Date of procedure/drop off Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20182019202020212022 If drop off, please fill out a patient report card. What procedure, surgery or treatment are we performing on your pet today? If lumpectomy, please be specific of where lumps are located and what we are removing. I, being responsible for the above stated animal, have the authority to grant you my consent to receive, prescribe for, treat and/or perform surgery upon my pet. I understand the surgery or treatment contemplated is: Enter surgery or treatment At Muddy Branch Veterinary Center care about your pet's safety and comfort. We require lab work, IV catheters, and IV fluids on all surgical cases, and pain relief to assist in post-surgical pain management. We offer the 911 Pet Chip! This chip has a one time implantation and registration fee. Would you like your pet to be microchipped with 911 Pet Chip? Yes No implanted previously Estimates: The estimate, which you may have been given, is based upon the entering examination of your pet and may change as further diagnostic and therapeutic procedures dictate. The estimate is just that, charges may change. Final charges will be based on the actual services provided. If we must exceed this estimate, we will work hard to contact you. Would you like the doctor to call you to discuss the estimate prior to starting the procedure? Yes No Dental Procedures: If your pet needs teeth extracted we will make every effort to contact you two times for consent. If we cannot reach you and you would like us to move forward with extraction of diseased teeth do you consent to us doing this knowing there are additional fees that can range from $200-$700 depending on the difficulty of extraction. Yes No Yes but not to exceed the amount entered below Amount not to exceed: $ Acceptance & Authorization: I understand and accept that the estimate may change. I understand that the treatment/surgery provided will be conducted with due care and in accordance with the prevailing standards of compentency in Veterinary Medicine and that no guarantee of assurance has been made as to the results that may be obtained through the course of treatment undertaken by Muddy Branch Veterinary Center, its Veterinarians, agents or employees. I also agree and understand that all anesthesia and surgery involves a certain amount of risk to my pet. I agree to be responsible for all charges relating to my pet's medical care. If any unforseen medical or surgical needs arise, I hereby consent to any medications and supplies purchased or prescribed and understand that additional costs will be my responsibility. I understand a deposit may be required for hospitalized animals. I agree to pay the balance of all charges in full at time of discharge. I also understand that the hospital is not staffed 24 hours a day. I understand that MBVC requires pre-anesthetic lab work along with pre and post pain medication for my pet if needed. I understand that Muddy Branch Veterinary Center does not offer after hours pick ups. A fee of $1 per minute late will be applied for late pick up from surgery or drop off procedures. I accept Signature of owner/responsible agent: Signer Name * What is the best number to reach you today? *
