Surgical Information Packet (Page 3 of 4) in pdf

Surgical & Anesthesia Consent Form

Owner’s Name:

Date:

Address:

Phone Numbers: (Home)

(Work)

(Cell)

E-mail address:

Animal’s Name:

Breed:

Sex:

Birthdate:

I certify that I own, or have authorization over, the above-described animal. I do hereby consent and authorize the

Glencoe Veterinary Clinic and its staff to hospitalize my pet and to administer vaccinations, medications, tests, surgical

procedures, anesthetics, or treatments that the doctors deem necessary for the health, safety & well-being of the above

animal while it is under their care and supervision.

 If the animal described above is a dog and is 7 months or older, proof of a negative heartworm test within the last

6 months must be provided prior to surgery. If no proof is provided, a heartworm test will be performed at your

expense.

 Young dogs and cats may have retained baby teeth, which will interfere with the growth of the adult teeth and/or

lead to other problems. While your pet is under anesthesia, we can remove any retained baby teeth.

 We offer a Microchip special to our surgical patients. Ask for details when you check your pet in for surgery.

***Please initial selected procedures you would like your animal to have***

Fees for selected procedures will be added to surgical cost.

I request a CBC & Surgical Profile prior to surgery

I request a Surgical Profile prior to surgery (Required if over 5 years of age)

Yes, I would like a Feline Leukemia/FIV/Heartworm test performed on my cat prior to surgery

Yes, I would like any retained baby teeth removed

Yes, I request a Microchip for my animal

I wave the request of a CBC and/or Profile (a heartworm test will still be performed on dogs without a current one)

Please name the procedure(s) you wish to have performed on your pet today:

If my pet should injure itself, refuse food, soil itself, become ill, or die while in the hospital, I will not hold the Glencoe

Veterinary Clinic and staff responsible and/or liable, in the absence of gross negligence.

Glencoe Veterinary Clinic’s vaccination policy states that the animal’s Rabies vaccination must be current. I

understand the clinic policy & will provide proof of current vaccination. I understand my pet will be vaccinated at

my expense if no proof is given.

I realize that I am responsible for payment at the time of discharge for the above procedures and treatments.

Please choose which of the following payment options you will be using:

CASH

CHECK

VISA/MASTERCARD/DISCOVER

CARECREDIT

Signature of person authorized to consent for patient:

Date:

PLEASE BRING THIS COMPLETED PACKET WITH YOU TO GLENCOE VETERINARY

CLINIC AT THE TIME OF SURGERY CHECK-IN

Surgical Information Packet Page 3

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