Page 1 of 2

Surgical/Anesthesia/Dental Consent Form

Pet owner name

Pet name

Primary phone number

Please list the reason for your pet's visit today and any other services you would like done while your pet is under anesthesia:

General Questions:

Is your pet on heartworm/flea/tick prevention?

Is your pet on heartworm/flea/tick prevention?
A
B

Has your pet been checked for internal parasites in the last 6 months?

Has your pet been checked for internal parasites in the last 6 months?
A
B

Has there been any vomiting, coughing, or diarrhea noted?

Has there been any vomiting, coughing, or diarrhea noted?
A
B

Has your pet eaten this morning?

Has your pet eaten this morning?
A
B

Has your pet been ill or injured in the past 30 days?

Has your pet been ill or injured in the past 30 days?
A
B

Would you like us to update any overdue vaccines for your pet today? Please note that in order to provide services a valid rabies vaccine is legally required in all pets*

Would you like us to update any overdue vaccines for your pet today? Please note that in order to provide services a valid rabies vaccine is legally required in all pets*
A
B

Is your pet allergic to any medications?

Is your pet allergic to any medications?
A
B

If yes, please list them:

Is your pet taking any medications currently?

Is your pet taking any medications currently?
A
B

If yes, please list them:

When Last Dose Was Given:

I would like to add a nail trim while my pet is sedated ($15.00 plus tax)

I would like to add a nail trim while my pet is sedated ($15.00 plus tax)
A
B

In-heat/Pregnant/Obese: Please note that there will be an additional charge for animals that are in heat/pregnant/obese.

Pre-Anesthetic Diagnostic Screening:

We recommend a diagnostic screening to be run before the surgery to help detect any internal problems that may not be evident upon a physical examination. This process includes drawing a single blood sample and/or urine. The costs of the recommended diagnostic screening are:

Pre-Anesthetic Diagnostic Screening:We recommend a diagnostic screening to be run before the surgery to help detect any internal problems that may not be evident upon a physical examination. This process includes drawing a single blood sample and/or urine. The costs of the recommended diagnostic screening are:
A
B

Cat Owners: We offer FELV/FIV Testing at the time of the procedure. This is recommended for cats who go outdoors for any period of time (particularly if they have fight and/or bite wounds) and multi-cat households.

Cat Owners: We offer FELV/FIV Testing at the time of the procedure. This is recommended for cats who go outdoors for any period of time (particularly if they have fight and/or bite wounds) and multi-cat households.
A
B

IV Catheters & Fluids: IV catheters allow quick access to stabilize your pet should anything arise. Fluid support during surgery helps maintain blood pressure and protect the organs.

IV Catheters & Fluids: IV catheters allow quick access to stabilize your pet should anything arise. Fluid support during surgery helps maintain blood pressure and protect the organs.
A
B

E-Collar: We recommend sending your animal home with an e-collar for all surgical procedures to prevent them from infecting the area by licking and chewing it.

E-Collar: We recommend sending your animal home with an e-collar for all surgical procedures to prevent them from infecting the area by licking and chewing it.
A
B

Dental Procedures:

Dental Procedures:
A

Pain Medication: Pain control for your pet is a very important part of the healing process. Pain medications are a part of all our surgeries. We may also recommend pain medications to go home with your pet depending on the procedure.

Micro-Chip: Micro-chip identification is a service we offer that allows your pet to be identified by a barcode scanner should he/she become lost. The micro-chip is inserted just under the skin between the shoulder blades. Animal control officers scan animals before they are destroyed.

Micro-Chip: Micro-chip identification is a service we offer that allows your pet to be identified by a barcode scanner should he/she become lost. The micro-chip is inserted just under the skin between the shoulder blades. Animal control officers scan animals before they are destroyed.
A
B

Payment: As the owner or authorized agent of this animal, I understand that I am responsible for payment in full at time of release. I agree to pay for these services by the following payment method. (Please initial one)

Payment: As the owner or authorized agent of this animal, I understand that I am responsible for payment in full at time of release. I agree to pay for these services by the following payment method. (Please initial one)

Would you like a treatment estimate?

Would you like a treatment estimate?
A
B