- 176 Skokie Valley Road
Highland Park, IL 60035
MM slash DD slash YYYY
Is your pet:
*One per line please*
A physical examination will be performed on your pet prior to the induction of anesthesia. The
pre-anesthetic exam includes vital signs and a thorough exam from head to tail. In some instances,
anesthesia may need to be postponed if certain physical abnormalities are discovered upon examination.
Pre-anesthetic Lab Work:
CBC/Chemistry Panel will give us more insight to life-threatening problems due to organ defects, anemia
and infection, etc., that are not evident on a physical exam.
I hereby authorize the clinic to perform such diagnostic, therapeutic and surgical procedures as described above. The nature of such services and risks have been described to me IN DETAIL, and I realize that no guarantee or warranty can ethically or professionally be made regarding the results or cure. Complications arising from anesthetic procedures may result and range from the simple to the very complicated as well as death. The undersigned is wholly responsible for any additional costs arising from the good faith efforts of our veterinarians and staff including but not limited to life saving CPR or referral for specialized medicine and treatment at referral centers. I also authorize the clinic staff in an emergency situation, to follow through with such procedures as are necessary for the well being of my pet on a continuing basis until further communication with me. I understand that I assume financial responsibility for all services rendered.