Owner InformationOwner Name* First Last Date* Date Format: MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country *We must be able to reach you while your pet(s) is/are at Bethel Animal Health. Please make it a priority to be available to take our calls regarding your pet(s) care.*Patient InformationPet's Name*Species*DogCatBreed*Age*As the owner or agent of the owner of the animal above, I hereby give my consent to Bethel Animal Health to perform the following procedure*It is our goal to keep all procedures as reasonably priced & as safe as possible. Our base price includes the services that we feel are most important for a successful surgery and comfortable experience for your pet. There are several other services that we feel are important to offer for safety & comfort. They are available at an additional fee 1. IV catheter- The IV catheter provides quick access to the veins in case of an emergency and assists in administration of IV medications. Fluid therapy can help stabilize and support healthy blood pressure.IV catheter only: $30*ApproveDeclineIV catheter plus fluid administration during procedure: $50*ApproveDecline2. Elizabethan Collar- This is a lamp shade cone that goes on your pet's neck to prevent licking/chewing of the surgical site. An e-collar is highly recommended to prevent post-operative damage to the surgical site. The owner is held financially responsible for all post-operative care needed as a result of not purchasing and e-collar or other post-operative needs. E-Collar cost: $10.50-$16.00*ApproveDecline3. Additional Anesthesia monitoring package - (Electrocardiogram & blood pressure) All surgical patients are monitored with a pulse oximeter, which reads their heart rate and blood oxygen levels during surgery. The additional monitoring package includes additional electrocardiogram (ECG) and blood pressure monitoring. An ECG assesses the heart function during anesthesia. Additional Monitoring $50*ApproveDeclineIf your pet has fleas it will be treated with a fast acting (24hr Effective) flea control in our hospital. Fleas are easily spread and put your pet and other pets here at risk. If the veterinarian deems it necessary to administer Capstar you will be obligated to a $6 fee. (Initial for understanding)*I certify that I own the above described animal and authorize Bethel Animal Health to hospitalize/treat said animal. During this time they may administer vaccinations, medications, tests, surgical procedures, anesthetics, or treatments they deem necessary for the health, safety, and wellbeing of my pet while the care and supervision of the hospital. I understand there are inherent risks associated with anesthetics, medical and surgical procedures, including death. I authorize the doctors of Bethel Animal Health to initiate care to address complication, should they arise while under their care. In the event of an emergency, the hospital will make every reasonable attempt to contact me so that I am aware of the situation, so I am involved in medical decisions. The contact phone numbers in my chart are correct. If my pet should injure itself in an escape attempt, refuse food, soil self, become ill, or die while in the hospital, I will hold Bethel Animal Health and staff free of all responsibility and/ or liability in the absence of gross negligence. I further realize that I am responsible for payment of all above mentioned procedures/ treatments in full at the time of my pets discharge. If I neglect to pick up my pet within 7 days of notice that my pet is being released, Bethel Animal Health may assume that the animal has been abandoned. In such instances, Bethel Animal Health is then authorized to take care of my pet as they see fit, including euthanasia or adoption. Abandonment however, does not release me of the responsibility of my obligation for payment of said bill.Signature*Date* Date Format: MM slash DD slash YYYY