Surgical Consent Form printable pdf download

Taylorsville Veterinary Clinic

4339 Ridge Road, Mount Airy, MD 21771 ● 410-875-5437 or 410-775-7007

SURGICAL CONSENT FORM

Owner’s Name: __________________________________________ Date: ___________________________________

Address: __________________________________City: ____________________ State: _________ Zip code: ________

Primary Phone Number: ____________________________Emergency Phone Number: __________________________

Animal’s Name: _______________________________ Breed: __________Sex: _______ Color: __________________

I, being responsible for the above animal, have the authority to grant my consent to prescribe, treat and/or perform surgery for

this pet. The surgery or treatment contemplated is:______________________________________________________

Taylorsville Veterinary Clinic is to use all reasonable precaution against injury, escape, or death of my pet, but will not be held

liable or responsible in any manner as it is thoroughly understood that I assume all risk.

 If patient is having a mass removal would you like to biopsy the specimen? Y / N

 If patient is having a dental cleaning, spay, or neuter, would you like a dental sealant applied to prevent

plaque buildup? The cost of this service is $25.00. Y / N

Pre-anesthesia Blood Screen:

Taylorsville Veterinary Clinic is proud to have a blood analyzer available to perform blood chemistries and complete blood

counts in the clinic before anesthesia. We will perform a complete physical exam on your pet before administering anesthesia.

However, we highly recommend a pre-operative blood screen for the purpose of insuring your pet is at minimal risk during

anesthesia. By performing the blood work, we are able to rule out most pre-existing internal problems that may not be evident on

physical examination. There is an additional $70.00 fee for this service.

______Yes, please complete the recommended blood work prior to surgery on my pet. If abnormalities are found, please call

me before proceeding with anesthesia of my pet.

______ No, I do not wish to have the recommended blood work performed on my pet at this time and request that you continue

with the surgical procedure.

Companion Laser Therapy:

We are excited to offer laser therapy for all post-surgical patients. Laser Therapy is a quick, surgery free, drug free, non-

invasive treatment to reduce pain, reduce inflammation and to increase the speed of healing post-operatively. The cost is an

additional $20.00 for this service.

_____Yes, please complete the laser therapy on my pet after surgery to provide immediate pain relief and increase speed of

healing. *There is additional information on laser therapy available upon request*

_____No, I do not wish to have laser therapy of my pet after surgery.

Permanent Identification System:

We are proud to offer a microchip companion retrieval system. A microchip is inserted under your pet’s skin, which allows for

the pet to be electronically identified for its entire life. The cost for this service is $64.00.

______ Yes, I’d like for my pet to be permanently identified with a microchip.

______ No, I am not interested at this time.

Maryland law requires us to notify you when there is no 24 hour supervision of pets that are left in the hospital overnight. At Taylorsville Veterinary Clinic,

we pride ourselves in providing the extra attention pets sometimes need when they are ill, which sometimes involves keeping your pet overnight. We insure

that it will be treated promptly before we leave at night as well as immediately the next morning. If your pet needs more intensive 24 hour observation, we

will make arrangements to see that your pet receives the care it deserves. In all cases, we request that you call in the morning for a report on your pet’s

health and notification of when it may return home.

SIGNATURE OF OWNER OR RESPONSIBLE AGENT: ______________________________________________