Name *

First

Last

Phone *

Email *

Pet's Name *

Species *

Dog
Cat
Other

If other, please specify *

Is your pet microchipped? *

Yes
No

Microchip Number *

I am the owner of the above mentioned animal or am responsible for it and hereby authorize the performance of the following procedure(s) *

Has your pet had any food since midnight last night? *

Yes
No

Please describe your pet's diet *

Has your pet been vomiting or having diarrhea? *

Yes
No

Date of last distemper + parvo vaccine *

Date of last Bordetella vaccine *

Date of last FVRCP vaccine *

Date of last Rabies vaccine *

Please list any medication(s) that your pet currently takes and the time last given *

I understand that the requested procedure(s) requires anesthesia and authorize the use of such anesthetics as the veterinarian deems advisable. I also realize the possible risks of individual adverse reactions with such drugs and agree to indemnify and hold the hospital and/or veterinarians harmless from and against any and all liability arising out of the performance of the procedure(s) referred to above. *

I have read and understand

Pain Medications:

Research and our own observations have confirmed that pets receiving anodynes or medications that relieve pain recover much faster than pets that are not given analgesic medications. Consequently, we will administer an analgesic prior to your pet undergoing any surgical procedure. Also, to aid in minimizing post-surgical pain, we will dispense an analgesic for you to give to your pet at home. These medications are included in the cost of the surgery.

Post-Anesthesia Nausea:

Humans undergoing anesthetics are given anti-nausea medications to reduce the side effects of anesthesia and some pain-relieving medications. Likewise, pets can experience nausea and reluctance to eat following an anesthetic; this uncomfortable feeling can sometimes lasting for days following surgery. We recommend offering your pet an injection of anti-nausea medication prior to surgery; this will add an additional $35-75 (depending on the size of your pet) to the cost of surgery.

1-50 lb: $35.00 51-120 lb: $55.00 121 lb and up: $75.00

Do you want your pet to receive an anti-nausea injection prior to surgery? *

Yes
No

Pre-Anesthesia Blood and/or Urine Testing:

Adequate kidney and liver function, as well as glucose, red blood cells, white blood cells, and platelets, are essential to the maintenance of health and for the metabolism and excretion of anesthesia agents. The test includes measurements of blood urea nitrogen (BUN), ALT, alkaline phosphatase, glucose, and creatinine to assess liver and kidney function; a complete blood count (CBC) to check for anemia, measure platelets (essential for blood clotting), and a breakdown of the various types of white blood cells necessary for healing and defense. If abnormalities are detected, the veterinarian will contact you, discuss the significance of the abnormalities, and may recommend further testing or special monitoring during and after the procedure. A pre-anesthesia test is recommended for ALL surgical patients and required for all pets over eight years of age.

Do you request the above listed test be performed? *

Yes
No

Signature *

Date *

Surgery Consent Form

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