Surgery Consent Form

Contact Name

Contact Phone Number

Contact Email Address

Contact Address

Contact Address 2

City

State / Province / Region

ZIP / Postal Code

Pet's Name

Pet Birthdate

Pet Species & Breed

Pet Breed

Pet Sex

SURGERY/PROCEDURE:

Additional Procedures:

Fasting for Surgery

What medication and when do they get them?

When did your pet last eat?

Is your pet currently taking any medications?

Yes No

Does your pet have any known medication allergies?

Yes No

Add Is your pet on Heartworm or Flea Preventions?

Yes No

Do you need a refill of prevention today?

Yes No

Other

DOG OWNERS

Heart worm testing is required annually to stay on Preventions. Does your need a heartworm test today?

Yes No

Other

Rabies, Distemper and Kennel Cough Vaccines are required to stay in the hospital for surgery. Is you pet up to date on these Vaccines?

Yes No

Other

Do you want us to radiograph your dog's hips while under anesthesia?

Yes No

CAT OWNERS

Rabies, Distemper and Kennel cough are required to stay in the hospital for surgery. Is your pet up to date on these vaccines?

Yes No

Testing for Feline Leukemia and FIV is recommended for cats.

Yes No

Other

Pre-Anesthetic Blood Screening *Required for pets 5 yrs and older*

Yes No already done

Microchip/Procedures

I would like a microchip

Yes No

I will need an e-collar

Yes No

Cerenia injection: Some patients may become nauseous during or after anesthesia. This injection will prevent and relieve for 24 hours.

Yes No

Histopath

If your pet is having a mass removal, would you like to send to the lab to determine the type of mass and margins.

Yes No

Pain Medications *Basic Pain Injection is Included*

We can administer an additional pain injection to help keep your pet more comfortable for 24 hours after their procedure.

Yes No

Other

Theraputic Laser can help increase circulation to the treated area. Leading to reduced inflammation, decrease pain and speed healing. I would like laser therapy for my pet

Yes No

Other

I would like pain meds to go home. This is an oral medication that can be given for several days after procedures to keep your pet more comfortable.

Yes No

Other

Dental Cleanings

If your pet is having a Dental cleaning, would you like us to take full mouth radiographs to help determine the health of each tooth.

Yes No

Other

After cleaning the teeth, we will evaluate which teeth may need removal. I would like all teeth that need extracting removed.

Yes No

Other

Some dogs will retain their puppy teeth. This can lead to increased Dental tartar. Would you like us to remove unnecessary puppy teeth?

Yes No

Other

I would like a phone call with an updated Estimate if extractions are found necessary after the cleaning and/ or radiographs.

Yes No

Other

In the event that unforeseen complications arise during your pet’s procedure, please indicate whether you authorize the veterinary team to take extensive or life-saving measures deemed medically necessary. This may include additional diagnostics, treatments, or procedures beyond those initially discussed. *

Initials

Authorization to Proceed

1. I authorize the use of appropriate anesthesia/medications and support the personnel judgment of the Veterinarian. I understand even though every precaution is taken, anytime an animal is anesthetized there is a slight risk that an adverse reaction could potentially occur resulting in death.

2. I understand that during the above listed procedures an unforeseen medical condition may become evident that necessitates an extension of or an addition to these procedures. I authorize the performance of such procedures as are perceived necessary in the professional judgment of the Veterinarian.

3. I understand that the result of any procedures/operation cannot be guaranteed. I am aware of the risks and understand the information presented in this consent form, and I give authorization to proceed with procedures/surgery and perform any and all life saving procedures should the need arise

Signature:

Date

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