- Cherry Eye Repair

Select Location*
Owner's Name*
First Last
Owner's Date of Birth*

(for dispensing controlled drugs)
Phone Number*
Secondary Phone Number
Pet's Name*
What date and time will your pet's last meal be given prior to dropping off?*
Approximately how much food does he/she eat?*
Is your pets condition better/worse/the same?*
What symptoms are you currently seeing?*
Did you bring your pets medications here today?*
Is your pet on any other medication(s) besides eye medications?*
Please list all medications your pet is currently on, frequency you give them and the last time they were given:*
Is your pet allergic to any medications?*
If so, please list the medication(s) below:
Has your pet had any adverse reaction to a medication (oral, topical, injectable, etc)?*
If so, please list the medication(s) below:
Has your pet ever had any adverse reaction to any procedures?*
If so, please list the procedure and what occurred below:
Is there anything else that you feel we should be aware of with regard to your pet’s health prior to surgery today?
Has your pet ever had any seizures?*
Has your pet ever had a past anesthetic event that you thought went poorly?*
Has there been any history of neck, spine, or back disease in your pet? Any pain or discomfort in these areas?*
Do you prefer eye ointments or drops?*
Do you prefer oral liquid medications or oral pills?*
Is your pet up to date with vaccinations?*
Do you have any questions for the doctor or about the surgery today?*
Would you like us to trim your pet's nails while they are under anesthesia? (Complimentary) Applies to General Anesthesia Only*
Only applies to General Anesthesia.
For our Diabetic patients, please fill out the following:
What is his/her regular insulin schedule? (Please indicate both the time you administer the insulin and the dose given each time.)
How much insulin was given today and at what time? How much food was also given?
Assumption of Risks
I am the owner or agent for the owner of the above animal and have the authority to execute this consent. I hereby consent and authorize the performance of the following procedure:
Replacement of the third eyelid gland(s)*
- Right Eye
- Left Eye
- Both Eyes
I understand that the third eyelid gland(s) may reprolapse which could require additional surgery at additional costs*
- Yes
- No
Risks of the above procedure(s) include (but are not limited to) the following: anesthetic complications including death, infection, reprolapse of gland, loss of tear production, corneal ulceration.
Please Sign or Initial Below
Please Read and Respond
I understand that because of unforeseen circumstances, the cost of rendered services may exceed the estimated cost. In this case, all charges are held as low as possible. The doctors and staff of Bay Area Animal Eye Care will be glad to go over itemization and explain any charges.*
Please Sign or Initial
I understand that it may be necessary, during the procedure or hospitalization, to provide emergency medical care in the event that I cannot be contacted. Therefore, I consent to and authorize the performance of such medical or surgical interventions as are necessary and desirable in the exercise of the veterinarian’s professional judgement.*
Please Sign or Initial
I also authorize the use of appropriate anesthetics, and other medications, and I understand that hospital support personnel will be employed as deemed necessary by the veterinarian.*
Please Sign or Initial
I have been advised as to the nature of the procedure(s) and the risks involved. I realize that results cannot be guaranteed.*
Please Sign or Initial
In the unlikely event of a cardiac or respiratory arrest during hospitalization or surgery, would you like the attending doctor to perform CPR to the best of our ability with the equipment available?*
Please Select One
The invoice total may vary 15% to 20%. A deposit is required at the time of drop-off. -This estimate you were given is only for services and does not include any other visits. I understand that visits following surgery will have their own fees which are due at the time of service. -I understand that I was given only an estimate of services. We want to give your pet the best possible care. In order to do so, we sometimes must run tests or procedures that we did not anticipate. We will do our very best to inform you of any additional tests and their costs before performing any unexpected but necessary procedures. -While the potential for anesthesia associated risks is quite low, serious and life threatening complications can arise associated with general anesthesia. I understand that anesthesia as described in this estimate is necessary for this procedure and I understand the risks and complications associated with anesthesia and the surgical procedure(s). -I understand that I am responsible for all medical expenses relating to the care of my pet in this hospital regardless of the eventual outcome. I will assume any attorney fees or collection costs resulting from my failure to pay these fees. -I am the owner or agent of the above described animal and I fully understand the terms of this agreement. Furthermore, I authorize Animal Eye Care to perform the above indicated services. -I understand that a $500 deposit is required at the time the surgery is scheduled. This deposit will be applied to the surgical invoice the day of surgery. -I also understand that the deposit is non-refundable unless the surgery is canceled within 72 business hours of the scheduled day. -I understand that a $1,000 deposit is required the day of the procedure/surgery prior to drop off. -This medical treatment plan and associated cost estimate is valid for 30 days.
Signature*
For the safety and comfort of our patients, we strongly encourage clients to pick up prescribed medications prior to patient discharge or immediately at the time of pickup. This is especially important for post-operative patients, as timely pain control and medication compliance are critical to recovery. If you choose to decline our in-house medications and request a prescription instead, we are happy to provide a written prescription, which is considered the equivalent of a medication at the time of discharge. Please note that once a prescription has been provided, our clinic is unable to dispense, modify, or place additional prescription calls after hours. Delays or difficulties obtaining medications externally may result in unnecessary discomfort for your pet and may require emergency care. Planning ahead helps ensure the best outcome for your pet and allows emergency services to remain available for true emergencies.
Signature*
Payment Acknowledgment
Payment may be made in the form of cash, personal check, VISA, or MASTERCARD. A fee of $35.00 will be added payable charges for returned checks. The balance must be paid in full before the animal will be released, as our policy does not permit delayed payments.
Please Enter Today's Date*
I have read and understand this authorization and consent.*
Please Sign or Initial

- Cherry Eye Repair

For our Diabetic patients, please fill out the following:

Assumption of Risks

Please Read and Respond

Payment Acknowledgment

Your Pet’s Vision is Our Top Priority!