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SEDATED RADIOGRAPH PATIENT INTAKE FORM

Owner Name:

Address:

Client Phone Number:

Pet's Name :

Species:

Breed:

Sex:

Age:

Color:

Weight:

Primary Contact Person & Phone #:

Emergency Person & Phone #:

When was the last time the patient ate?

Is patient on any medication?

Is patient on any medication?
A
B

If so, give the name of the medication, dosage and last time administered

What is the patient here for?

Platelet Rich Plasma (PRP): Please indicate whether or not you would like PRP injected into the joint of your pet's surgical leg. (check one)

Platelet Rich Plasma (PRP): Please indicate whether or not you would like PRP injected into the joint of your pet's surgical leg. (check one)
A
B

If applicable: Indicate whether or not you would like PRP injected into the joint of your pet's non-surgical leg as well. (check one)

If applicable: Indicate whether or not you would like PRP injected into the joint of your pet's non-surgical leg as well. (check one)
A
B
I am aware that if additional injections take place in the future, additional charges may accrue.
I hereby authorize performance of the above procedure. The nature of such service has been described to me to my satisfaction and I realize that no guarantee no warranty can ethically or professionally be made regarding the results or cure. I understand that I assume financial responsibility for all services rendered, and that payment is due upon
hospital discharge of the patient.

Signature of Owner or Authorized Agent:

Signature

Date: