Surgical Consent Form printable pdf download

Surgical Consent Form

For Spaying, Neutering and Declawing

Owner’s Name:_____________________________________________ Date:____________________

Owner’s Address:___________________________ City:______________ State:____ Zip:__________

Pet’s Name:________________________________ Dog:_____ Cat:_____

Male:_____ Female:____

Breed:___________________ Age:_______ Color/Description:_______________________________

Phone number(s) Primary: (____)__________________ Secondary: (____)___________________

Please initial to authorize the following procedure(s):

Spay (females) _______ Neuter (males) _______ Declaw (cats) ________

I understand that anesthesia will be used and that with anesthesia there is always a risk, although minimal, of

an allergic reaction or even death of the animal. A pre-surgical visual exam will be done on all animals to help

minimize this risk. Any animals found to have a condition that increases the risks of the anesthesia will not be

operated on until the owner has been advised of the risks. Any female dog found to be in heat will be refused.

The nature of the surgery to be performed has been explained to me satisfactorily I understand that I assume

financial responsibility for all services rendered, and that payment will be expected when the animal is picked

up from their surgery.

Pre-surgical Bloodwork: These 4 blood tests evaluate: kidney function, red blood cell level, blood protein, and

blood sugar. Having these tests done prior to surgery helps our Doctor make the appropriate decisions while

your pet is having surgery and helps minimize the inherent risks of anesthesia. The cost for testing is $12.50

I want the bloodwork:______ I DON’T want the bloodwork:______

Signature of owner or agent____________________________________ Date:________________

These additional services can be performed on your pet at the same time as your pet’s surgery. All of these services are RECOMMENDED, but

not required for the continued health of your pet.

Canine Heartworm Test $22.00______

Feline Leukemia/ FIV Combo test $30.00_______

Rabies Vaccine $12.50______

Feline Leukemia test ONLY $22.00________

Canine Distemper/Parvo (5 way) $13.50_______

Feline Leukemia Vaccine $17.50_________

Canine Bordetella $13.50___________

Feline Upper Respiratory/ Distemper Vaccine $13.50_______

Fecal Exam for worms $10.00 _________

Microchip $38.00 __________

Surgical Consent Form