Animal Owner Name
*
First Name
Last Name
Animal Owner Phone:
*
Animal Name
*
Species / Breed
*
My pet is having the following surgery performed
*
I am aware my pet is not to be fed on the day of his/her surgery
*
Yes
No
My pet will require an Elizabeth collar after surgery
*
Yes
No
Not sure
I will be giving prescribed medications to my pet prior to being dropped off for surgery:
*
Yes (Please list below)
No
Has your pet recently had diarrhoea or been vomiting?
*
Yes
No
Does your pet require a special diet?
*
Yes (Please list below)
No
I have agreed to the cost estimate provided to me and acknowledge there may be a 15% variance, and also that the estimate does not cover extra costs incurred in an anaesthetic or other health emergency during my pet's surgery, such as fluid therapy.
*
Yes
No
I am aware the agreed cost estimate does not include follow up treatment or x-rays required.
*
Yes
No
Anaesthetic and surgical risks have been explained to me, and I have been given the opportunity to discuss these with the Veterinarian.
*
Yes
No
While my pet is in your care, please provide these additional treatments. I am aware the cost will be added to the agreed estimate.
Pre-anaesthetic blood tests have been offered to me, I understand they can help idendify unknown health issues which may affect the Vet's choice of drugs used on my pet.
*
Yes
No
I, being over 18 years of age and the owner of the animal mentioned above, give my permission to the treatments outlined above. I have received sufficient information about the risks involved with my pet's treatment / procedure / surgery and the possibility and nature of further related treatment should any complications arise.
*
Yes
No
I agree to settle all costs of treatment at the time of my pet's discharge, and accept it if my account is not paid, my details will be forwarded to a debt collection agency. I also understand that the debt collection costs will be added to my account.
*
Yes
No
Should my pet be found to have fleas, I agree to treatment at my cost.
Yes
No
I hereby GIVE / DO NOT GIVE RVC and all RVC subsidiaries, permission to take photographs, videos of either me or my pet for any lawful use, including and not limited to website, educational and promotional activities or materials, or social media platforms. I hereby release and discharge RVC from any and all claims arising out of the use use of the photos.
Yes - Pet only
Yes - Myself and my pet
No
