Please read carefully and fill out the form completely. AUTHORIZATION FOR PROFESSIONAL SERVICES Owner’s NamePet’s NameBreed:Age:SexAddress Street Address City State / Province / Region ZIP / Postal Code Daytime Phone#Evening Phone#I hereby authorize the following surgical procedure to be performed by Doctor Connelly: The nature of such service has been described to me to my satisfaction and I realize that no guarantee or warranty can ethically or professionally be made regarding the results or cure. I also understand that I assume financial responsibility for all services rendered, and that payment is due upon dismissal of my pet. Signature of ClientDate Date Format: MM slash DD slash YYYY Before putting your pet under anesthesia, we will perform a full physical exam. However, many conditions such as liver, kidney, or blood disorders cannot be detected unless a blood test is performed. This testing is mandatory for all pets prior to any surgical procedures. For pets under 1 year of age the cost is $51.00. More comprehensive testing is required for pets over 1 year of age, and the cost is $74.00. Our lab is fully equipped to give results immediately, before any anesthesia or surgery is performed.SignaturePet’s NamePOST SURGERY PAIN MANAGEMENTFor Dogs:Yes, I would like additional pain medication for my dog after surgery.If needed. Please send home pain medication for my pet if the doctor recommends it.For Cats:Yes, I would like additional pain medication for my cat after surgery. (Required for declaw surgeries)If needed. Please send home pain medication for my pet if the doctor recommends it.Microchipping is a method of permanently identifying your pet. If they become lost or stolen, an animal with a microchip can be positively identified and returned to their owner even if they have lost their collar. The cost is $49.00Yes, I would like to have a microchip inserted in my pet.No, I am not interested in this pet retrieval offer.My pet is already micro chipped.*Any pets found to have fleas will be treated at owner’s expense.