Surgery Consent Form

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Marek Veterinary Clinic
W: _______
T: _______
Anesthesia / Sedation / Surgery Consent Form
Date: ____________ Owner: _______________________ Pet’s Name: ___________________
Species: _________ Breed: ___________ Sex: M___F___ Color: _________ Age: ________
Address: ________________________________________ City/State/Zip:__________________
Contact Phone Number: __________________________________________________________
As the owner or agent of the above listed animal(s), I hereby give my consent to Marek Veterinary Clinic to perform the
following procedure(s):
Pre-anesthetic Bloodwork – Recommended prior to ANY procedure requiring sedation or anesthesia.
______ I would like to have pre-anesthetic bloodwork performed.
______ I decline any pre-anesthetic testing prior to sedation/anesthesia.
* Sedation/Anesthesia WILL NOT be performed if the waiver is not initialed*
Dental Waiver:
______ I request that therapy/extractions be performed at the doctor’s discretion.
______ I request that I be consulted prior to any therapy/extractions.
Please accept or decline the following additional procedures, which will be performed at owner’s expense:
Post-operative Pain Injection: Y
N
Flea Control
Y
N
Canine Heartworm Test
Y
N
Heartworm Prevention:
Y
N
Feline Leukemia/FIV Test
Y
N
E-Collar
Y
N
Fecal/Oral Dewormer
Y
N
Vaccinations
Y
N
Microchip
Y
N
List Vaccines requested: ______________________
*** All animals receiving treatment or surgery MUST have proof of rabies vaccination given within the last 12 months or the animal
WILL be vaccinated at the time of visit at owner’s expense. Fleas and ticks will also be treated at the owner’s expense.***
I understand that during the performance of a procedure, unforeseen conditions may be revealed that could necessitate an extension or
variance of the procedure. I expect Marek Veterinary Clinic to exercise reasonable care and judgment in these cases. I understand the
nature and risks involved in these procedures and I realize that results cannot be guaranteed. I am also aware that unforeseen events
that may result with this animal will not relieve me from any obligation to all reasonable costs incurred.
Signature/Date _____________________________________

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