Surgical Consent Form printable pdf download

SURGICAL CONSENT FORM

Client:_____________________________________________________ Date:___________________________

Patient:_______________________________________________ Species:______________________________

Procedure:___________________________________________________________________________________

PRE-ANESTHETIC TESTING (Required for animals over the age of 7):

Our greatest concern is the well-being of your pet. Before putting your pet under anesthesia, we recommend a

pre-anesthetic blood test (CBC/Chem) and/or a coagulation screening test (PT/APTT) to help reduce many of the

risks of surgery. Certain conditions including disorders of the liver, kidneys and blood can increase the risks of

surgery. These conditions are not apparent upon physical examination and cannot be identified until a blood test

is performed.

I want my pet to have a CBC/Chem screen performed prior to anesthesia: ($59.30)

YES /

I want my pet to have a PT/APTT performed prior to anesthesia ($35.00) :

YES /

INTRAVENOUS FLUIDS (Mandatory for mature & large breed dog spays and other major surgical procedures):

Administration of intravenous fluids will help to maintain your pet’s blood pressure and increase his/her

circulation during their anesthetic. It will also help him/her to recover more quickly. The intravenous catheter is

also used to administer medication if needed.

I want my pet to have IV fluids during his/her anesthetic: ($71.10)

YES /

PET IDENTIFICATION:

We highly recommend a tattoo and/or microchip to identify your pet. In the event that he/she goes missing,

tattooing and micro-chipping can help to ensure that your pet is returned safely back to you.

I want a TATTOO for my pet ($15.00):

YES /

I want a MICROCHIP for my pet ($75.20):

YES /

PAIN MEDICATION:

Pain medication is included in your surgery price. Pain medication helps to reduce discomfort and inflammation

after surgery.

Please give my pet a complimentary NAIL TRIM while he/she is under anesthetic:

YES /

By signing below, I authorize anesthetic/surgery for my pet. While Central Animal Hospital provides the highest

quality of anesthetic monitoring and surgical services, I understand the nature and risks of this procedure that

have been explained to me and I am encouraged to discuss any concerns with the veterinarian before the

procedure(s) are started. I understand that the veterinarians and hospital team will do everything possible to

reduce any risks and I will not hold Central Animal Hospital, the veterinarians or any team member liable for any

complications that may arise.

Client Signature:____________________________ Phone Number(s):___________________________________

WE MUST BE ABLE TO REACH YOU IN CASE OF AN EMERGENCY!

Surgical Consent Form