North Shore Animal Hospital

One Neptune Blvd

Lynn, MA 01902

(781)596-0510

Date: ______

Your Full Name: ______Pet’s Name:______

Address: ______Sex: ______

City, State, Zip: ______DOB: ______

Phone Number: ______Breed/Color: ______

PLEASE VERIFY THAT THE ABOVE INFORMATION IS CORRECT.

______(pet’s name) is being admitted to our hospital to undergo a surgical and/or dental procedurerequiring anesthesia. Anesthetic procedures involve an inherent risk and results cannot be guaranteed. We have minimized the risk of anesthesia by using modern and safe anesthetic agents.In addition, all pets are given a physical examination prior to the scheduled procedure. An appropriate injectable pain relief medication will be administered immediatelyfollowing surgery. This medication will control pain and keep your pet comfortable here and athome. Your pet will have a faster recovery time and be less likely to have surgicalcomplications.

There will be additional charges for pain relievers and for animals that are in heat or pregnant or excessively over weight and are undergoing a spay/neuter surgery. The charges for pain relievers will not exceed $45. Please discuss quotes with the receptionist. We recommend, to further insure the safety of your pet, a preoperative blood screening. This screening is similar to those used in human hospitals and is available to assess your pet's risk for certain complications. The blood is analyzed in our laboratory prior to surgery. Your pet's preoperative blood screen may include tests to evaluate liver and kidney function, blood sugar level, or for other blood abnormalities. Sick animals or animals over seven years of age will have blood tests performed. The receptionist can explain various fees ($55.00 to $185.00). Pets found to have fleas or evidence of fleas (flea dirt) will be treated with an appropriateflea product and your account will be charged accordingly.

YES --I have read the above and agree to this lab work for my pet. If any significantabnormalities are found, contact me at the number below.

NO --I have read the above and elect not to have the lab work performed. By declining requiredblood tests, I realize that the procedure may be cancelled. I agree to hold North Shore Animal

Hospital, Inc. harmless in the event of anesthetic, surgical or medical complications that mighthave been detected had these tests been performed.

Please be aware that there is not a twenty four hour on site staff member available at thehospital.

All fees must be paid in full at the time services are performed

or upon discharge from the hospital. Any exception to this policy must be authorized prior to the performance of any service. We accept cash, only checks approved via Telecheck (Must have ID), Master Card, Visa, American Express, Care Credit and Discover for your convenience.

I am the owner (or owner's agent) of (Pet’s Name)______. I understand that I am authorizing performance ofthe following procedure(s):

PROCEDURE: (LISTALLPROCEDURES)______

All animals admitted must be current on their core vaccinations. If we have no record of your pet'svaccines, please provide vaccine certificates.

Additionally, we highly recommend thatdogs be vaccinated for Lyme disease, tested for heartworm and Lyme disease and maintained onheartwormpreventative throughout the year. We recommend that all cats be tested for leukemiaand FIV and received leukemia vaccine if at risk for exposure. We recommend that all dogs andcats be tested for internal parasites, use flea/tick preventatives and be microchipped.

While your pet is under anesthesia, would you like any of the following recommended servicesperformed? Be advised that there will be additional fees related to your selections below.

Feline Leukemia/FIV Test $58

Vaccinations Ask for Quote $

Treat for Fleas Ask forQuote $

Express Anal Sacs $35

Implant Microchip & Register $54 (Registration Only $25 )

Nail Trim $4

Ear Cleaning $6

Heartworm (4DX)Test $61

Other, please specify______

Please discuss fees and any questions and concerns with your receptionist.

PROCEDURE AUTHORIZATION for (Pets Name)______belonging to (Owner) ______:

I have had the reasons for surgery or anesthesia explained to me and I am satisfied with the planof management for ______. I have also had the likely fees explained to me and acceptresponsibility for payment of these fees at the time of ______'s discharge.

Please confirm the address above as well as the phone numbers and email address below by completing the appropriate boxes:

Home Phone: ______Cell Phone: ______

Alternate Phone Number:______

Email Address: ______

Signed: ______

Print Name of Person Authorizing Procdure(s______

Owner or Agent, please indicate who is authorizing.

North Shore Animal Hospital Witness: ______

Date______

PLEASE BE SURE TO LEAVE A PHONE NUMBER WHERE WE CAN REACH YOU

THIS MORNING AND THROUGHOUT THE DAY.