Owner's Name *

First

Last

Secondary Owner's Name

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

County *

Primary Phone *

Secondary Phone

Email *

May we text you instructions, updates, etc. to the phone numbers provided? *

Yes
No

If “Yes” please select which number, we can text *

Primary Phone
Secondary Phone
Both

Communication Preference *

Call
Text
Email

Pet's Name *

Species *

Dog
Cat

Sex *

Male
Male (neutered)
Female
Female (spayed)

Age/Date of Birth *

Breed *

Color *

Is your cat indoor only or indoor and outdoors? *

Indoor only
Indoor and Outdoors
Indoor and Outdoors (outdoors only with supervision)

Is your pet fearful or aggressive around strangers? *

After any surgery, it is possible your pet will want to lick or chew at the surgery site. Therefore, we include an e-collar with this surgery. We also have surgical suits available for $35 plus tax. *

I accept a surgical suit for my pet
I decline a surgical suit and will just receive the e-collar

Animal Works Veterinary Surgery requires a Pre-Anesthetic Profile for all emergency procedures. Our Pre-Anesthetic Profile checks your pet's organ functions to see if we need to alter our anesthetic protocol or medications to go home. If your pet has recently had blood work performed at another clinic, please provide this with other records. In certain situations, it may be advised to repeat blood work if there was any concern. *

Pre-Anesthetic Profile (Required with all emergency procedures)
My pet has recently had blood work performed at another clinic within the last 24 hours

Please list any medical conditions, allergens, previous surgeries, or other vital information regarding your pet. If you have nothing to add, please put "none" in this section. *

Please list any medications or supplements that you currently give to your pet. If you have nothing to add, please put "none" in this section. *

Additional comments or concerns? Please list them below.

Is your pet up to date on vaccinations? *

Yes
No

If so, what clinic may we contact to inquire about records? *

Procedure being performed *

I certify that I am the owner or the authorized agent for the owner of the animal listed above. I grant the veterinarians and staff of Animal Works Veterinary Surgery my consent and authorization for the above procedure to be performed. The nature of the operation or procedure(s) has been explained to me, and I understand what will be done. I fully understand that Animal Works veterinarians are Colorado licensed doctors of veterinary medicine but are not veterinary specialists and maintain and continue to give my consent. I understand that unforeseen conditions may be revealed that necessitate an extension or variance in the procedure(s) set forth above for the safety of my pet. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian’s professional judgment. I accept responsibility for any result in additional fees. I understand Animal Works Veterinary Surgery will use all reasonable precautions against injury, escape, or death of the animal but will not be held liable or responsible in any manner. I further understand certain risks are involved when any pet is given anesthesia and/or undergoes a surgical/dental procedure. The amount of risk depends on many factors including but not limited to; the nature of the emergency and how long the pet has had the issue, general physical condition, condition of the heart and internal organs. I understand that Animal Works Veterinary Surgery will make every effort to minimize the risk but no guarantees can be made as to results or cure and that I am still responsible for all fees, no matter the outcome. I agree to the use of any photograph(s) or video(s) of me and/or my pet for educational and promotional purposes for Animal Works Veterinary Surgery (including but not limited to: web pages, newsletters, brochures, and displays. I further understand that I will not be paid for the use of such photograph(s) or video(s). My signature below signifies that I am over 18 years of age. *

I have read and understand

Anesthetic/Sedation Risks: Although every effort is made to make anesthesia/sedation as safe as possible, there are inherent, unavoidable, assumed risks with any anesthetic procedure, and results cannot be guaranteed. These risks have been explained to me, and I am encouraged to discuss any concerns I have about the risks with the staff at Animal Works Veterinary Surgery before the procedure is performed. *

I have read and understand

Intravenous Catheter Placement & Fluid administration during surgery/ recovery: I fully understand my pet may receive intravenous (IV) fluids during the procedure to help maintain hydration, normal blood pressure and support the cardiovascular system. If your pet receives IV Fluids, they may have a shaved area on the front of their leg as the hair must be removed to allow the area to be disinfected properly before inserting the catheter; this area will be bandaged and can be taken off once you arrive home. The fee for intravenous catheter placement, catheter maintenance, and intravenous fluid administration during surgery and recovery is included in the procedure unless noted by the staff of Animal Works Veterinary Surgery. *

I have read and understand

I fully understand that Animal Works Veterinary Surgery is a surgical center and not a 24-hour hospital. I accept these limitations of service and have been informed to take my pet to a 24-hour hospital if complications arise after surgery or treatment. On rare occasions, Animal Works Veterinary Surgery may offer to keep my pet overnight, I understand that no staff will be attending to my pet during this time. I assume the risk If I choose to, upon my own accord, to take my pet to any other veterinary hospital before or after surgery. I fully understand the Animal Works Veterinary Surgery will not be liable for any charges incurred from the treatment that was given at any other veterinary-related facility or hospital. *

I have read and understand

I further agree to make prompt and complete payment for all treatment upon discharge of the above pet. I also understand and agree that in case of non-payment or non-pick up within 24 hours, Animal Works may relinquish my pet to a local rescue or shelter of their choosing. I will be subject to all billing and/ or finance charges associated with my account. Should it become necessary to settle my account through a collection agency or attorney I, the undersigned, agree to pay all costs of collections. *

I have read and understand

I agree that a digitally scanned or photographic copy of this authorization and instruction shall be as valid as the original, even if my digital signature is not complete or legible. *

I have read and understand

Digital Signature *

Date *

Emergency Authorization Form

Please complete this form before your visit.

Got questions?
Feel free to contact us.

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