Date

Client’s Name:*

Pet’s Name*

Age

Gender

Procedure(s)

I, the undersigned owner or agent of the owner of the cat identified above, certify that I am _______ , I am not _________ (Check one below) eighteen years of age or older and authorize the veterinarians at this practice to perform the above procedure(s). I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the veterinarian before the procedure(s) is/are initiated. While I accept that all procedure(s) will be performed to the best of the abilities of the staff at this clinic, I understand that veterinary medicine is not an exact science and that no guarantee or warranty has been made regarding the results that may be achieved.

I am*

Eighteen years of age or older
Not eighteen years of age or older

Every patient is combed for fleas. If fleas are found on your cat, we will treat the cat at your cost.*

(Initials)

ANESTHESIA/SEDATION PROCEDURES

If your cat is undergoing a sedation or anesthesia procedure, some risk always exists. Because of this we require blood tests on all cats 8 years and older and recommend it for those under 8 years. Pre-surgery blood work consists of a CBC which checks blood cells and chemistries which check blood sugar, kidney, liver and heart functions. The test cost is $223.79.*

My cat is 8 years or older (required) or under 8 years (optional), I consent to blood work. If any abnormalities are found, we will contact you prior to proceeding
My cat is under 8 years of age OR has already had the required blood work run within the last 3 months.

My cat has not consumed food this morning.*

(Initial) Cats can vomit food under anesthesia and inhale into their lungs causing death.

Feline Leukemia/Feline AIDS tests

I would like to have the Feline leukemia/Feline AIDS test run at an additional cost of $76.00.*

Yes
No

MICROCHIP:

A microchip is inserted under the skin on the back of the neck. This chip registers you and your cat’s information and also allows for us to scan your cat’s temperature without a thermometer. If your cat is lost, a shelter or veterinary hospital is required to scan for a chip prior to adopting out or euthanizing. The cost for this procedure is $58.00 + tax

I would like my cat microchipped*

Yes
No

BIOPSIES

(for lump/tumor removals only)

I would like my cat’s lump/tumor sent to the lab for biopsy

Yes
No

DENTALS

I have been informed that examination under anesthesia may reveal loose teeth that fall out or should be extracted to prevent oral discomfort and ongoing infection. I understand that:

This facility provides basic feline dental cleanings and extractions of visibly loose or diseased teeth only.

We do not have dental radiology (dental X-rays) available at our facility.

We do not perform advanced oral surgery or root-extractions (removal of residual roots or surgical extraction), which require referral to a board-certified dental specialist.

In some cases, small fragments of roots may remain after extraction of loose teeth; these typically do not cause problems but there is risk of inflammation or ongoing issues.

If significant inflammation, discomfort, or suspected residual root fragments develop later, referral to a dental specialist may be recommended. I consent to the necessary extractions at the discretion of the doctor, within the scope of the facility’s services.

OVERNIGHT STAYS

In the event the doctor recommends an overnight stay (spays, declaws, cystotomy etc.), I understand that continuous presence of personnel is not provided during those hours.

I opt to*

Leave my cat at the discretion of the doctor
Pick up my cat and provide care in my home, in which case I accept all risks
Take my cat to a 24 hour facility for overnight care at my own expense

LIFE SAVING EMERGENCY

Should lifesaving emergency care such as CPR be required and the clinic staff is unable to reach me, the staff has my permission to provide lifesaving emergency treatment. If these services are provided, I understand I am responsible to pay for this service. The cost would not exceed $100.00.*

Yes
No

I acknowledge that I am responsible for payment in full for the above procedure and treatments at the time my cat is discharged.
If your cat is being hospitalized for treatment or non-routine surgery, a $200.00 deposit is required.
I further agree that I, or an authorized agent, will pick up this cat and pay for all accrued charges within five days of receiving written or oral notification that my cat is ready to be released. Such notice will be given at the phone/address maintained on the clinic’s patient/client record. I understand that if I fail to comply with this policy, the practice will handle this as an abandonment case, and I will be responsible for all fees incurred.

SIGNATURE OF OWNER (Authorized Agent)*

EMERGENCY PHONE NUMBER*

*For your cat's safety, please note all cats must be in a carrier at drop off.*

Date

ALLENTOWN CAT CLINIC HAS PERMISSION TO POST MY CAT ON SOCIAL MEDIA*

Yes
No

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Staff Signature

FOR STAFF USE ONLY: ADMITTING STAFF INITIALS _____________

Monday	8:00am – 12:00pm \| 1:00pm – 6:00pm
Tuesday	8:00am – 6:00pm
Wednesday	8:00am – 6:00pm
Thursday	8:00am – 6:00pm
Friday	8:00am – 5:00pm
Saturday	Closed
Sunday	Closed

Anesthesia Authorization