Surgical Consent Form
ADVERTISEMENT
1
2
3Animal Clinic of Council Bluffs Surgical Consent Form
Owner:
Patient:
Pet’s Name____________________
Name:___________________________
Address:_________________________
Age__________________________
________________________________
Circle: Dog Cat Male Female Spayed/Neutered
As the owner or agent of the owner of the above animal, I hereby give my consent to Animal Clinic of
Council Bluffs to perform the following procedure(s):
Procedures requiring anesthesia are always associated with a certain amount of risk, whether the
patient is a person or a pet. Like you, we want to minimize that risk as much as possible - this requires
a physical exam (if the pet has not been seen within the past few weeks) and pre-anesthetic tests.
General anesthesia has become safer in recent years with the advent of newer drugs and better
patient monitoring. Some conditions may not, however, be evident on a physical exam. To better
ensure your pet's safety during anesthesia, we advise the following pre-anesthetic tests be performed,
even for elective procedures such as spays, declaws, and neuters.
□
Healthy patient under 7 years of age
Mini-blood chemistry profile & complete blood cell count
□
Sick patients or patients over 7 years of age
Comprehensive blood chemistry profile, complete blood cell count, thyroid check, & complete
urinalysis
□
Coagulation Profile
Checks for bleeding disorders and to be sure the patient can clot their blood.
□
ECG to check for abnormal heart arrhythmias
□
FeLV/FIV/Heartworm Test (Feline Patients only)
Please Initial
_______YES—Please complete the recommended/chosen pre-anesthetic testing
prior to anesthesia for <animal>.
_______NO—I decline the recommended pre-anesthetic blood tests at this time and
request that you proceed with anesthesia.
While your pet is in the clinic, would you like the following services performed (at a discounted rate):
□ Request
□ Decline
Nail Trim
□ Request
□ Decline
Ear Cleaning
□ Request
□ Decline
Ear Pluck
□ Request
□ Decline
Fecal Parasite Exam
□ Request
□ Decline
Express Anal Glands
□ Request
□ Decline
Microchip Implantation
We recommend that all pets have a means of permanent identification
Pets must be current on vaccinations or they will be given at the owner’s expense.
Page 1
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal