Surgical Consent Form printable pdf download

Surgical Consent Form

Staff Members Initials:________

Current Vaccines: YES / NO / N/A

Owner and Pet Information

Owner’s Name: _____________________________________________________ Date: ______________________

Emergency Contact Phone: _____________________________ Cell Phone: ______________________________

Pet’s Name: _____________________________________ Breed:____________________ Color: ______________

I am the owner or the authorized agent for the owner of the animal described above, and I have the

authority to execute this consent.

Surgery Information

Procedure to Perform:

Mass Removal

Laceration Repair

Other: ___________________

__________________________________________________________________

Additional Services:

Pre-Surgical Bloodwork

Pre-surgical bloodwork is a in-house chemistry panel that does a examination of your pet's liver

and kidney function to help determine if you pet is able to handle general anesthesia today. Any

abnormalities will be brought to your attention and the proper course of action taken. By

checking “No” you decline the pre-surgical bloodwork for your pet. By checking “Yes” you give

Hickory Small Animal permission to perform the pre-surgical bloodwork at a additional cost of

$42.50

5 Yes

5 No

Pain Medication

AAfter most surgical procedures, your pet will experience some pain. Hickory Small Animal

Hospital offers post surgical pain medications to limit this discomfort and allow your pet to rest

comfortably. We can give your pet a pain injection before surgery for an additional $13.00.

5 Yes please give my pet a pain injection

5 No, do not give my pet a pain injection

before the surgery.

We can also send home pain medications for an additional cost of $__________.

PAIN MEDICATIONS ARE HIGHLY RECOMMENDED

5 Yes please send my pet home with take

5 No, do not send my pet home with take

home pain medication.

Surgical Consent Form