Surgical Consent Form



Surgical Consent Form

Owner_______________________________________ Pet’s Name_____________________________

Phone number in event of emergency:_______________________ Alternate Phone_____________________

As the owner or agent of the owner of the above animal, I hereby give my consent to the Eastpoint Veterinary Clinic to perform the following procedure(s):

Spay 􀁒 Declaw 􀁒 2 feet or 4 feet Growth Removal 􀁒

Neuter 􀁒 Dental 􀁒 Other 􀁒 _____________

Therapeutic Nail Trim 􀁒 IV Cath/Fluids 􀁒

1. Does your pet show any signs of illness? Yes 􀁒 No 􀁒

2. Is your pet taking any medication? Yes 􀁒 No 􀁒

3. Has your pet had any previous reactions to anesthesia? Yes 􀁒 No 􀁒

Laboratory Tests Waiver

If your pet is to be anesthetized, rest assured that advances in anesthesia and surgery have made routine procedures relatively safe with a low rate of complications. Nevertheless, occasional problems can arise due to pre-existing conditions not evident during routine pre-anesthetic examinations. We recommend that prior to anesthesia, the following laboratory tests be performed and that you will be charged for them.

Pre Surgical Bloodwork It is our job to ensure that your pet can properly process and then eliminate the anesthetic he or she is given. Before we perform any procedure that requires anesthesia, we run tests to confirm that your pet’s liver, kidneys, and blood cells are functioning properly and to reveal any hidden health conditions that could put your pet at risk. Your pet’s health and safety are our number one priority!

Please Initial One

5 years and under $60.40 ____ Over 5 years $101.90_____ I Decline bloodwork ____

_____Microchipping (Permanent Pet Identification) A microchipped pet can be positively identified and returned home safely should they become lost or stolen (even if they have lost their collar and tags) We offer a discount to have it done while undergoing surgery, so it is painless to your pet. We use Home Again Pet Recovery Service. The cost is $72.00 (this includes registration).

AUTHORIZATION

I verify I am the owner (or authorized agent for the owner) of the above named pet and authorize the above

procedure to be performed. I understand that pets that are overdue for vaccines are required to be made current during time of hospitalization. I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure(s) as directed by the veterinarian. I have been advised as to the nature of this procedure to be performed and the risks involved. I understand also that there is always a risk associated with any anesthesia episode, even in apparently healthy animals and have discussed my concerns with the veterinarian. I understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated for the safety or care of my pet. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian’s professional judgement. I accept responsibility for any result in additional charges. I agree to be responsible for any charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital. I understand no staff will be attending to my pet overnight (pets needing special care may be referred to a 24 hour hospital).

Date_______ Signature of Owner/Agent__________________________

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