Preston Center Animal ClinicAuthorization for Surgical Treatment This form authorizes Preston Center Animal Clinic, 5934 W. Northwest Hwy, Dallas, TX 75225 to perform the procedures listed below.Note: This form must be filled out completely and submitted before your pet can undergo any surgical procedure. Thank you!Your name *Date Patient Name *Procedure to be performed *Attention: All patients requiring general anesthesia will receive pre-operative blood testing, IV catheterization, IV fluid therapy, pain medications, injectable and/or inhalant anesthesia, endotracheal intubation, electronic monitoring, and body heat maintenance support.Please select your preference if your pet is here for a dental cleaning *Select the third option if your pet is not receiving dental services during this procedure.YES, I accept any dental extractions if indicated during a dental cleaning.NO, I would like to be notified before any dental extractions during a dental cleaning.My pet is not here for a dental cleaning.Additional Services Please select any of the following services that you would like to add to your pet's procedure:HOME-AGAIN Microchip (placement and registration fee is $68.70 + tax)Nail trim (Dogs $20 + tax, Cats $15 + tax)Anal gland expression ($25 + tax)Phone *Please list a number where you can be reached for questions and/or when the procedure is complete.Alternative phone number *In the event that we can't reach you at the above number, please list a secondary number (office, spouse, etc)Agreement The nature of these operations or procedures has been explained to me, and I understand what will be done. I have also been informed that there are certain risks and complications associated with any operation or procedure of this type. I further understand that during the operations or procedures, unforeseen conditions may arise that may necessitate the performance of additional procedures. I authorize the use of appropriate anesthesia and pain relief medication as needed before or after the procedure.Electronic Signature Your electronic signature below, represented by typing your full name into the block as your authorizing signature, constitutes your acknowledgement that you have read and agree to the above, the procedures or surgery has been explained to your satisfaction and that you have all the information you desire, you have had the chance to ask questions, and you authorize and consent to the performance of the procedure and to the administration of anesthesia.Electronic Signature Block *Please type your full name as your authorizing signature. VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank:
