Surgical Consent Form printable pdf download

Radnor Veterinary Hospital

Surgical Consent Form

107 North Aberdeen Ave

Wayne, PA 19087

Owner’s Name ___________________________________ Pet’s Name ____________________________

Please list any medications your pet is currently taking ____________________________________________________

When was the last time any medication(s) was given? ______________________________________________________

Surgical Consent:

I give Radnor Veterinary Hospital my permission to perform a/an _____________________________________________

Pre-Anesthetic Blood Testing

Like you, our greatest concern is the well being of your pet. Radnor Veterinary Hospital (RVH) will perform a complete physical

examination on the day of surgery. However, many conditions, including disorders of the liver, kidney, or blood are not detected

unless blood testing is performed. Such tests are especially beneficial prior to any anesthetic procedure. Our in house laboratory is

fully equipped and staffed to perform these tests. Results are available within minutes for examination by the doctor prior to

anesthesia and/or surgery. The cost of these important tests is $55.00.

Age 6 or Younger:

___ YES, I want my pet to have a pre-anesthetic blood screen

___No, I do not want my pet to have a pre-anesthetic blood screen

Age 7 or Older:

WITHOUT EXCEPTION, animals age 7 or older will receive a CBC and Chemistry at a cost of $131, and a mandatory IV catheter

placement and fluids at a cost of $81.

_____ My pet is 7 years or Older

HOME AGAIN MICROCHIP

This is an identification system for tracking lost pets. Implanting the microchip can be done in the office anytime or today while your

pet is under anesthesia. The cost is $69 for the permanent chip placement and registration.

______ Yes, I want my pet to receive a microchip

______ No, I do not want my pet to receive a microchip

DENTAL PROCEDURES – During a dental procedure, there may be tooth extractions, dependent upon the severity of dental disease.

If you have any questions, please feel free to ask before the procedure takes place.

I understand that during the performance of the foregoing procedure(s), unforeseen conditions may be revealed that necessitate an

extension of the foregoing procedure(s) than those set forth above. Therefore, I hereby consent to the performance of such

procedure(s) as are necessary and desirable in the exercise of the veterinarian’s professional judgment. I also authorize the use of

appropriate anesthetics and other medications, and I understand that Hospital support personnel will be employed as deemed

necessary by the veterinarian. I have been advised as to the nature of the procedures or operations. I have been able to ask

questions and have been informed of the risks involved. I understand that anesthesia, sedation and or surgery have inherent risks

including death. Due to the nature of the medicine, I also realize that results cannot be guaranteed.

PAYMENT MUST BE MADE IN FULL BEFORE PATIENT CAN BE DISCHARGED FROM THE HOSPITAL. ANY OTHER ARRANGEMENTS MUST

BE AGREED TO BY HOSPITAL MANAGEMENT.

Before treatment is initiated or services rendered, would you like a written estimate of cost? _____ YES _____NO

I HAVE READ AND UNDERSTAND THIS AUTHORIZATION AND CONSENT.

X___________________________________________________________________________________________________________

Signature of Owner or Agent

Emergency Phone for Today

Date

Surgical Consent Form