Cypresswood Animal Clinic Spay/Neuter Consent Form
Cypresswood Animal Clinic Spay/Neuter Consent Form
Date: __________ BEST PHONE NUMBER TO BE REACHED TODAY________________________
Client Name: _________________________________Patient Name:________________
Breed: ________________________ DOB/Age: __________________ Male / Female
Type of Procedure(s): _________________________
HAVE YOU EVER SEEN YOUR PET SUFFER FROM A SEIZURE? YES NO Date of last seizure: ____________
Please initial accept/decline below next to each service
______I understand I will be billed $11 for a flea pill if live fleas are found during the exam
________ I understand there will be an additional fee if my pet is in heat, pregnant or aggressive. $30
$12 Rabies Vaccination *REQUIRED* _____ Yes, my pet needs this _____ No, I brought proof of current Rabies
All surgeries include a pre-anesthetic examination
Additional Services Requested (Additional fee listed for each service)
Canine Core Vaccines: Basic vaccine package includes a DHLPPC, Bordetella, intestinal parasite screening, a heartworm test, and Rabies.
The SuperDog package includes the Basic package as well as a Complete Blood Count and Chemistry panel sent to an outside laboratory.
Basic Package $134.50 (inc Rabies) SuperDog Package $187.00(inc rabies) I want ONLY the following:
_____ I ACCEPT Basic package _____ I ACCEPT SuperDog _____ DHLPPC $25 _____ Heartworm Test $27.50
_____ I DECLINE Basic package _____ I DECLINE SuperDog ____ Bordetella $25 ____ Int Parasite Screening $20
(Vaccine Packages do NOT include cost of surgery)
[pic]
Feline Core Vaccines: Basic vaccine package includes the FVRCP – FeLk which helps protect against upper respiratory viruses including Feline Leukemia, an intestinal parasite screening, and Rabies. The Super Cat package includes Basic package, Complete Blood Count and Chemistry panel sent to an outside laboratory.
Basic Package $92.00 SuperCat Package $154.50 I want ONLY the following:
_____ I ACCEPT Basic package _____ I ACCEPT SuperCat _____ FVRCP-Felk $30 _____ Felk/FIV Test $30
_____ I DECLINE Basic package _____ I DECLINE SuperCat _____ Intestinal Parasite Screening $20
(Vaccine Packages do NOT include cost of surgery)
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Yearly Labwork (CBC/Chemistry Profile): We recommend that bloodwork tests be performed yearly. These tests can help us detect anemia, dehydration, diabetes, kidney disease and liver disease. (MANDATORY for all pets 5 years of age and older) Cost is $145 _____ I ACCEPT pre-anesthetic lab work _____ I DECLINE pre-anesthetic lab work
IV Catheter: Allows quick access to a vein in the event of an emergency. (MANDATORY for all pets 5 years of age and older, and Pregnant Females) Cost is $35
_____ I ACCEPT an IV Catheter _____ I DECLINE an IV catheter
Microchip Identification: We recommend that every pet that comes into our facility have a microchip placed. Microchips are a permanent form of identification in the event of your pet being lost or stolen. Cost is $37.50
_____ I ACCEPT a microchip _____ I DECLINE a microchip
Extract deciduous (baby) teeth: Occasionally pets will have retained deciduous teeth that will not fall out on their own. If these teeth are not removed they create overcrowding in the mouth which causes excess buildup of tartar and bacteria – it is HIGHLY recommended that these teeth be removed if they are present. (Removing teeth at a later date will require additional sedation charges) Cost is $10 per tooth
_____ I ACCEPT extraction of baby teeth if present _____ I DECLINE extraction of baby teeth
_____ Nail Trim $10 _____ E-Collar $6-$20 (If your pet begins to lick the incision, an E-Collar will be placed on your pet)
____ 5 days of Pain Medications Dogs: $10-$30 / Cats: 72hr injection $15
I hereby authorize and direct the veterinarians of Cypresswood Animal Clinic to perform the procedures and additional diagnostic and/or treatment procedures as deemed advisable for my pet. The nature of the procedure(s) has/have been explained to me. I understand that there may be risk involved in some of these procedures, including DEATH. I agree to pay, IN FULL, for services rendered, including those deemed necessary for medical or surgical complications or unforeseen circumstances. Any estimates or charges for the planned procedures are only approximations, and the final bill may be greater or less than these amounts. All services MUST be paid for when your pet is released.
_____________________________________________________________ ______________
Signature Date
*PETS WILL BE READY TO BE PICKED UP AFTER 4:00PM (5:00pm for CATS) UNLESS OTHERWISE INFORMED*
_____ I have received discharge instructions, discharge papers, and any additional medications I requested.
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Official Use Only
Wt: _______________
Temp: _____________
P: _________________
C: _________________
_____________: #_____
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