Sandhills Animal Hospital Consent

Sandhills Animal Hospital Consent

Medical Procedure Consent Form
Date

Month Day Year
Date
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Pet's Name
Species
Breed
Sex (M/F, MN (male neutered), FS (female spayed))
Has this pet eaten today? If yes, when & what did he/she eat?
As the owner or agent of the owner to the above animal, I hereby give my consent to Sandhills Animal Hospital to perform the following procedures:
Ovariohysterectomy (Spay): Est: $129-215 (weight dependent) Inc: Pre-surgical physical exam, 24 hours pain injection (19.73-41.77), anesthesia, surgery, additional $25 if in heat or obese, abbreviated or full chemistry required if over 6 years

Consent for Spay as described above CBC $42 (assess platelets, red and white blood cells) Abbreviated chemistry $54 (screen kidney, liver and pancreatic function for anesthesia and surgical risks) Full Blood chemistry $76 (total body screen of organs for anesthesia and surgical risks) Electrolytes $35 (Sodium, Potassium and Chloride for fluid administration and screen for anesthesia and surgical risks) Peri-operative fluids $35 (IV fluids run while asleep to maintain blood pressure- required if over 6 years) Elizabethan collar est $8-36 depending on size
Castration: Est: $110-165 (weight dependent) Inc: Pre-surgical physical exam, 24 hours pain injection (19.73-41.77), anesthesia, surgery, abbreviated or full chemistry required if over 6 years

Consent for castration as described above CBC $42 (assess platelets, red and white blood cells) Abbreviated chemistry $54 (screen kidney, liver and pancreatic function for anesthesia and surgical risks) Full Blood chemistry $76 (total body screen of organs for anesthesia and surgical risks) Electrolytes $35 (Sodium, Potassium and Chloride for fluid administration and screen for anesthesia and surgical risks) Peri-operative fluids $35 (IV fluids run while asleep to maintain blood pressure- required if over 6 years) Elizabethan collar est $8-36 depending on size
Blood Health Check

Abbreviated Chemistry: $54 Kidney, liver and pancreatic screen - 6 values Total Organ Screen $76 (total body screen of organs - 12 values) Blood Parasite Screen $46.50 (occult heartworm test, 3 tick diseases (ehrlichiosis, anaplasmosis and lyme disease))Type option 3 Occult Heartworm test $37 Feline Leukemia/Feline Aids/Feline Heartworm disease $37 CBC $42 (complete blood count - platelets, red and white cells) Clotting test $37
Additional Services Available

Intestinal parasite screen (fecal float) $18 (with direct smear for sick pets) $28 Nail trim $16 Dental Cleaning under anesthesia ($35-95 in addition to anesthesia $50) Polish/Fluoride application under anesthesia $15 Wart / Mass removal ($15 - 95)(Pathology $110) Radiographs $110 Bath $25-35 Flea treatment - Capstar $7-9, Topical $25-65 Microchip Placement $25
Vaccines

Rabies 1-year $16, 3-year $25 (rabies is required by law for dogs, cats and ferrets) DHPP/CVL $33 (distemper, hepatitis, parainfluenza, parvovirus, corona virus and leptospirosis) DHPP/L $ (distemper, hepatitis, parainfluenza, parvovirus, and leptospirosis) DHPP/CV $28 ( (distemper, hepatitis, parainfluenza, parvovirus and corona virus) DHPP $21 (distemper, hepatitis, parainfluenza and parvovirus) Lyme Disease $26 Bordetella $16 (kennel cough) Influenza $32 (canine influenza, recommended under same circumstances as Bordetella) FVRCP/FeLV $36 FVRCP $
Other Procedures Not Listed Above
I understand that during the performance of these procedure (s), unforeseen conditions may be revealed that necessitate an extension or variance in the procedure (s) set forth above. I expect Sandhills Animal Hospital to use reasonable care and judgement in performing the procedures (s). The nature of the procedure (s) and risks involved have been explained to me and I realize results cannont be guaranteed. I am also aware that unforeseen events resulting form the procedure (s) will not relieve me from any obligaiont to all reasonable costs incurred regarding the animal.

ALL ANIMALS ADMITTED MUST BE CURRENT ON THEIR VACCINATIONS (MINIMUM RABIES AND PARVO) AND FREE OF EXTERNAL PARASITE (FLEAS AND TICKS). BOOSTER VACCINES WILL BE ADMINISTERED TO NON-VACCINATED PETS AT THE OWNER'S EXPENSE. aNY ANIMAL FOUND TO HAVE FLEAS OR TICKS WILL BE TREATED AT THE OWNER'S EXPENSE.
Signature of Owner/Agent: By signing, I decline all unchecked procedures and have been informed of the risks of my declination.

Clear
Technician or Doctor advising owner/agent of risks/benefits of the above consented procedures
Email
example@example.com
Phone Number

Area Code Phone Number
Should be Empty:

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