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Authorization Form - Lumpectomy
THANK YOU for choosing our Hospital! Please feel free to contact us if you have any questions regarding any of our services. IMPORTANT: Service dates and arrangements are not confirmed until you have received notification. A staff member will contact you by phone or email.
Authorization - I Am Authorizing The Following Procedures: Blood Work, IV Fluids, General Anesthesia, Lumpectomy, Antibiotic Injection, Analgesic Injection, Nail Trim, Possible Medication To Go Home.
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Accept
Decline
IF YOU CHOOSE DECLINE PLEASE DO NOT FILL OUT THE FOLLOWING FORM AND CALL OUR HOSPITAL.
Name
*
First
Last
Email
*
Phone
*
Pet Name
*
Has your pet been here before?
*
Yes
No
Please fill out any Comments or Special Instructions below: (Request for additional veterinary services, etc.)
Drop off Date
*
Date Format: MM slash DD slash YYYY
Drop off Time - Must Be Between 7a.m. - 9a.m.
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:
HH
MM
AM
PM
I can be contacted at anytime during the day of the procedure at the following number:
*
First
Last
Phone
*
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