I understand that the cost involved in the requested procedure(s) are to be paid in full at the time of my pet's release. 
I am the owner or agent of the above named pet and hereby authorize the performance of the requested procedures. I understand that unforeseen conditions may necessitate any extention of the procedure/treatment or a change in the plan and therefore authorize such action as are necessary in the professional judgement of the veterinarian. I authorize the use of appropriate anesthetics and medications. I have been advised of the nature of the procedure and I understand that while every effort will be made to provide the best care for my pet, results cannot be guaranteed. 
I have read the above information. I understand and agree to the conditions and policies of Lebanon Small Animal Clinic.Inc. 
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Client Name
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Has your pet eaten anything in past 12 hours?
Has your pet has any medication in the past 24 hours?
Has your pet had any vaccinations within the last 12 months?
Has your pets been treated for fleas within the last 30 days?
Has your dog been tested for Heartworms in the last year?
Additional Requested Procedures
If your pet requires pain medication to be sent home, would you prefer

By signing here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By signing here, you are waiving that right. After consent, you may, upon written request to us obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary. 

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