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A 10-year reflection
Acupuncture & TCVM A Natural Approach to Pain Relief? Pain
Rosie's Story
Ear cleaning with Dr. Couch
Separation Anxiety in Dogs
COVID-19 and the Effects on East-West Animal Hospital and the Veterinary Community
Healthy Mouth, Healthy Pet
Grain-free diets and your dog
Vaccines and your pet
Puppy Strangles
Pruritis: Itching and scratching in dogs
Fear Free Fun Visits!
Pet Insurance
Hills recalling can dog food
Cat Friendly Festivities
EWAH Procedure, Anesthesia & Medical Authorization Release Form
*
Indicates required field
Client Name
*
First
Last
Pet's Name
*
Procedure to be performed:
*
Phone Number where you CAN be reached
*
I certify that I am the owner, or authorized agent for the owner, of the above animal. I hereby consent to and authorize the doctors and staff at this veterinary practice to admit this pet, perform the above described procedures, and administer medications, anesthesia, surgical procedures, tests and or treatments that the doctors deem necessary for its health, safety and well being while under their care and supervision. I have been advised of the nature of the procedures and the potential risks and benefits. I understand that veterinary medicine is an inexact science and that no guarantee of successful treatment can be made.
I acknowledge that I am responsible for payment in full for the above procedures and treatments at the time my pet is discharged.
Owner / Authorized agent
*
Choose one
I am the owner and I agree
I am the authorized agent and I agree
I am neither
Consent for Cardiopulmonary Resuscitation (CPR)
Should my pet require cardiopulmonary resuscitation (CPR), including cardiac compression, defibrillation, positive pressure respiration, emergency drugs, or other heroic interventions, I request that the doctor(s) at this hospital pursue such medical care as indicated below. Having requested such emergency procedures, I agree to be held responsible for a minimum resuscitation fee of $175.00 + medications to pay for the services performed while staff members pursue treatment and try to reach me for further directions. Regardless of my pet’s survival, I agree to pay this fee in addition to the other fees already identified by the practice and agreed upon by me.
I request one of the following CPR services (please initial the appropriate choice):
1. Endotracheal intubation, positive pressure respiration, administration of emergency drugs, and/or external cardiac
massage ~$215.00 + medications. (CPR)
2. I elect not to have the staff pursue any CPR procedures for my pet and, instead, request that the attending doctor assist
my pet in dying in a peaceful manner. Do not resuscitate (DNR).
CPR option
*
Choose one
I elect number 1 above - CPR
I elect number 2 above - DNR
I accept that if the hospital staff is unable to reach me within 15 - 30 minutes after the initiation of CPR procedures, and after exercising reasonable medical judgment, determine that there appears to be virtually no hope for medical success, they will cease further CPR procedures. I understand that despite the best efforts of the doctors and staff at this facility, even the most successful CPR that restores my pet’s life may not allow my pet to regain his/her normal mental and physical health and, thus, may leave him/her as an invalid.
Intravenous (IV) Catheter and Pain Medication
Your pet will have an IV catheter placed to medications and fluid therapy during and after the procedure. This will assist in hydration and recovery after being anesthetized and help to move the anesthesia out of the body. It will also allow immediate treatment of possible anesthetic reaction or side effects.
A pain injection WILL be given to your pet to reduce pain and discomfort.
Laser Therapy
MLS Therapy is a therapy for treating pain, inflammation, and edema as well as repairing superficial lesions. Laser emissions have an immediate effect on pain and act fast on inflammation, stimulating blood and lymphatic circulation which induces reabsorption of fluids. EWAH recommends at least 1 session, an optimum 3 sessions post procedure.
1 - Post-operative laser session $33.00
3 - Post-operative laser sessions, 1 post-op and 1 at each post-op exam 1 week apart $82.50.
Laser Therapy Options
*
Choose one
Yes I want one (1) laser therapy session
Yes I want three (3) laser therapy sessions
No I do not want any laser therapy sessions
Microchip
Microchips are a safe, effective, and permanent way for rescuers to identify your pet in the event of an emergency. The procedure is equivalent to an injection, using a larger needle to insert the microchip. Our microchips will also take your pet's temperature! No more rectal thermometer :). It also includes lifetime registration.
Microchip Option
*
Choose one
My pet is currently microchipped
Yes, implant
No, I do not want my pet microchipped
Dental Procedures
If your pet is here for a dental procedure the doctor has given them a preliminary dental grade that may include a certain number of extractions. Dependent upon the results of the dental radiographs, there may be the need for additional extractions. We are looking at what is in the best interest of your pet, we prefer not to extract, but it is sometimes necessary.
1. Yes, you may extract necessary teeth
2. No, I do not want any extractions performed on my pet
3. I understand my pet is not scheduled for a dental procedure; if the doctor determines there are unhealthy teeth that
should be removed, I authorize those extraction only, understanding there is an additional cost.
4. My pet is not scheduled for any oral procedures. If something is noted, please call the contact number listed above
Dental procedure options
*
Choose one
Option 1 - yes extract necessary
Option 2 - no to extractions
Option 3 - not scheduled, okay if unhealthy
Option 4 - not scheduled, please call
Soft Tissue / Growth Removal (Biopsy)
If your pet is to have a mass removal, we often recommend submitting the sample to the laboratory for histopathology (identification). We ask your permission to submit the sample to the lab.
Histopathology Options
*
Choose one
Yes please submit the sample
I would like to speak with Doctor before deciding
No I do not want to submit the sample
AUTHORIZATION
By completing and submitting this form, I authorize the veterinarian to examine, prescribe for, or treat my pet. I assume all responsibility for charges incurred for the care of my pet. I also understand all charges will be paid at the time of discharge and a deposit may be required for surgical treatment.
Please authorize this acknowledgement and the answers to the questions above by entering your full name below.
Name
*
First
Last
Date completed
*
Submit
Home
COVID-19 Appointment Procedures
About
Veterinarians
Team - Techs & Assistants
Team - CSRs
Join our Team!
Services
Services
Acupuncture & TCVM
>
What to expect with TCVM
Types of Acupuncture Techniques
Behavior
Dental Care
>
What's a Dental Grade?
Products to Help Prevent Dental Disease
Other Dental Conditions
Laboratory & Diagnostics
>
Laboratory
X-ray / Radiographic Diagnostics
Microchips
MLS Laser Therapy
Modified Vaccine Protocol
>
Titers & Medical Exemption Letters
Stance Analysis
Surgery
Ultrasound, Echo & Endoscopy with Dr. Ludlow
Wellness - Preventative Care Plans
Client / Patient Center
Client Center
>
Annual Client Form & Hospital Policies
Pet & Pet Parent Social Media Agreement
Payment Options
Patient Center
>
Pet Information
Pre-Visit Questionnaire (PVQ)
Behavior Questionnaires
Admit & Anesthesia Release
Admit & Non-Anesthetic Release
Fear Free
Contact
Resources
Blog Center
A 10-year reflection
Acupuncture & TCVM A Natural Approach to Pain Relief? Pain
Rosie's Story
Ear cleaning with Dr. Couch
Separation Anxiety in Dogs
COVID-19 and the Effects on East-West Animal Hospital and the Veterinary Community
Healthy Mouth, Healthy Pet
Grain-free diets and your dog
Vaccines and your pet
Puppy Strangles
Pruritis: Itching and scratching in dogs
Fear Free Fun Visits!
Pet Insurance
Hills recalling can dog food
Cat Friendly Festivities