Fillable Surgical Consent Form printable pdf download

DATE: ________________

SURGICAL CONSENT FORM

Please read carefully and sign

Owner’s Name

Pet’s Name

Breed:

Sex:

Age:

Color:

Daytime Phone:

Evening Phone:

Other:

All animals must be current on all vaccinations and free of external parasites (Fleas and/or ticks) prior to surgery. Vaccinations and

/or parasite treatment will be given at owner’s expense.

As the owner or owner’s agent of this animal, I hereby give my consent to Hope Animal Clinic to perform the following procedure -

____________________________ ($40.00 add’l fee – Preg. Or In-Heat Spay plus cost of antibiotics)

I, being responsible for the above pet, have the authority to grant you consent to receive, prescribe for, treat and/or operate on this pet. I

understand that the doctor and staff will use all reasonable precaution against injury, escape and the death of my pet. I understand that all

anesthesia involves some minimal risk to my pet and I will not hold you liable or responsible in any manner whatsoever or under any

circumstances in connection therewith as it is thoroughly understood that I assume all risks. I accept full financial responsibility for my pet. I

am also aware that unforeseen events resulting from the procedure(s) will not relieve me from any obligation for all reasonable costs incurred

regarding this animal.

I understand and agree that Hope Animal Clinic is NOT responsible for any expenses I incur if I do not follow their post-operative surgical

recommendations.

___________________________________Owner/Agent

Before putting your pet under anesthesia, the veterinarian will perform a full physical exam to identify any existing medical conditions that

could complicate the procedure or compromise the health of your pet. Because the possibility exists that a physical exam alone will not

identify all of your pet’s health problems, we strongly recommend that a surgical blood profile be performed. The fee is $41.00. This

bloodwork can lead to early diagnosis of various health issues. Bloodwork is REQUIRED on any pet over 7 years of age.

______ Please COMPLETE the recommended blood testing prior to administering anesthesia to my pet.

______ I DECLINE the recommended blood testing at this time and request that you proceed with anesthesia. I understand that my pet’s

health could be at risk if a medical condition goes undetected when my pet is placed under anesthesia.

____________________________________Owner/Agent

ADDITIONAL SERVICES:

Veterinary professionals recognize the beneficial effects of pain management in post-operative surgical patients. We offer pain medication

post-operatively to all our surgical patients. As we have kept our fees for routine surgical procedures relatively low, there is an additional fee,

according to weight, for a post-operative pain injection.

I REQUEST P/M _________________________(initial)

I DECLINE P/M___________________________(initial)

We offer Laser Therapy. Treating an incision site immediately following surgery with laser promotes healing, decreases inflammation and

quickens the recovery period. The charge for this service is $10.00.

I REQUEST laser tx ______________________(initial)

I DECLINE laser tx________________________(initial)

We offer “HOME AGAIN” microchip transmitters for companion animal retrieval with registry in the AKC national recovery system.

Microchip identification allows your animal to be identified as yours in the event of accidental loss or escape so it may be returned safely to

you. Most animal shelters, Humane Society offices and major vet clinics are equipped with microchip scanners for stray animal

identification. The cost of microchipping and your pet and registering is $38.75.

I REQUEST a M/C _______________________(initial)

I DECLINE a M/C________________________(initial)

Surgical Consent Form

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