Surgery Consent Form

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J.M. PET VET
REGISTRATION & SURGICAL CONSENT FORM
Where your pet is a part of our family
Name of owner: ___________________________________________ Date: ___________________________________
Address: ____________________________________________ City: __________________________ Zip: ___________
E-mail (1): ______________________________________ E-Mail (2): _________________________________________
Home phone: __________________________________ Work phone: _____________________________ ext. _______
Cell phone (1): ______________________________________ Cell phone (2): __________________________________
May we contact you via text message? Yes__ No__ If so, pls list cell phone provider: ____________________________
Pet’s name: ____________________________________ Breed: ____________________________________________
Sex: M ___ F ___ Spayed/Neutered: Yes__ No__
Pet’s DOB: _________________
How did you hear about J.M. Pet Vet? __________________________________________________________________
MEDICAL HISTORY
Are your pet’s vaccinations current? Yes__ No__
Did your pet eat this morning? Yes__ No__
Has your pet recently experienced vomiting, coughing, sneezing or diarrhea? Yes__ No__
Is your pet allergic to any drugs? Yes__ No__ If so, pls list drugs: ____________________________________________
_________________________________________________________________________________________________
Is your pet currently on any medications? Yes__ No__ If yes, pls list medications:________________________________
_________________________________________________________________________________________________
Has your pet been ill or injured within the last 30 days? Yes__ No__ If yes, pls explain: ___________________________
_________________________________________________________________________________________________
Would you like us to check any other problems? Yes__ No__ If so, pls list problems: _____________________________
_________________________________________________________________________________________________
POTENTIAL COMPLICATIONS OF SPAY/NEUTER SURGERY
Common:
Uncommon:
Scrotal swelling and bruising in male dogs that resolve without treatment.
Ø
Anesthetic or surgical complications resulting in death.
Ø
Self inflicted trauma to the surgery site, this includes suture removal by the
Ø
Other anesthetic or surgical complications resolving with treatment.
Ø
animal, skin infections caused by licking or contact with unclean surfaces, and
Hernias resulting from breakdown of suture requiring surgical
Ø
other damage. These problems can be prevented by discouraging your dog
repair.
from licking, and purchasing and placing a cone over its’ head if uncontrollable.
Internal bleeding during or after surgery that can result in death.
Ø
Hematoma or Seroma (a collection of blood or fluid) around the surgery site or
Ø
Surgical site infections at or around the suture site.
Ø
in the scrotum, that will cause enlargement of the scrotum, but will resolve
Internal adhesions (scaring) that could impair gastrointestinal or
Ø
over time.
urinary tract function.
Minor swelling or redness around the incision, often related to minor reaction
Ø
Possibility of other unforeseen complications.
Ø
to the absorbable sutures, this will also resolve over time without treatment.
If your female pet is in heat, pregnant, or has pyometra (uterine infection), please be prepared for additional charges.
If your male pet is cryptorchid (retained testicle), please be prepared for additional charges.
Female animals will receive a small tattoo to their underside indicating they have been sterilized. This is a universally recognized tattoo
that would prevent unnecessary surgery should your pet live with someone else in the future.
I, the undersigned owner or agent of the pet identified above, authorize the staff of J.M. Pet Vet to perform the above procedure(s). I
understand sedation and anesthesia involves risk to my pet and that staff member will use all reasonable precautions against the injury,
escape or death of my pet. If this animal should injure itself in an escape attempt, soil itself, become ill, be exposed to infectious disease or
die while in the clinic, I will hold J.M. Pet Vet free of any responsibility and/or liability in connection with this procedure. All animals
admitted must be current on rabies vaccinations and must be free of external parasites. Any animal found to have fleas, ticks or ear mites
will be treated at the owner’s expense. I agree to pay in full for services rendered at the time of discharge.
By signing below, you are indicating your agreement of the terms hereof in this surgical consent form.
Procedure: Anesthesia & ______________________________
Print Name: ________________________________________ Owner’s Signature: _____________________________
1014 Pearl Street, Brockton MA 02301 / 508.588.5661 /
Rev. 3/16

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