Surgical Consent Form

Owner's Name *

First Name Last Name

Pet's Name *

Email *

example@example.com

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone number where you can be reached today *

Area Code Phone Number

Would you like a text message or a phone call when your pet is ready to be picked up? *

Text message Phone call

Has anyone in your household experienced any COVID-like symptoms (fever, coughing, shortness of breath, etc.) in the last 2 weeks? *

Yes No

Has anyone in your household tested positive for COVID-19 in the last 2 weeks? *

Yes No

Has anyone in your household been exposed to anyone with a positive COVID-19 test result in the last 2 weeks? *

Yes No

If you answered "Yes" to any of the COVID-19 screening questions above, we will still see your pet, but we will take extra precautions. You are also welcome to have a friend bring your pet in for you and we will call you if we have any questions.

Would you like to update your pet's photo for their chart? If so, please click "Browse Files" and select their picture.

Browse Files

What procedure are we performing today? *

Spay (Female alteration) Neuter (Male alteration) Mass removal

Please list all medications your pet is on and the last time they were given. *

Has your pet had any food since 10:00pm? *

Yes No

Does your pet have a history of seizures? *

Yes No

Does your pet have a history of adverse drug/vaccine reactions? *

Yes No

If yes, please describe the drug/vaccine reaction.

Has your pet shown any signs of coughing or exercise intolerance? *

Yes No

Has your pet vomited or had diarrhea in the last 48 hours? *

Yes No

If your female dog is here to be spayed, has she been in heat in the last 4 weeks? *

Yes No

At Companion Animal Clinic we strive to practice quality medicine. Human hospitals require laboratory testing before anesthetic procedures. To proceed in the safest manner possible, we STRONGLY RECOMMEND that pets are also properly screened. The results of laboratory blood screening can warn us about underlying conditions that could lead to complications. We are especially concerned with the kidney and liver functions as these are the primary organs that metabolize anesthetic drugs. The complete blood count is also important as this can identify underlying infections, anemia or clotting problems. Please indicate whether you accept or decline this service.
*Please note that any patients age 5 or over are required to have this blood panel done prior to anesthesia.*

CBC/CHEM 10 PANEL (Price: $95.99) includes: complete blood count, liver values, kidney values, protein levels and blood sugar level *

Yes, I accept to have this test run on my pet No, I decline to have this test run on my pet

If your pet is here for a mass removal, would you like histopathology done to determine type of mass and help determine prognosis? *

Yes ($285.00 for priority results in 1-3 business days) Yes ($182.00 for standard results in 3-5 business days) No My pet is not having a mass removed today

Spays and neuters will receive a pain injection that lasts 24 hours for no additional charge. However, sometimes post-operative pain can last a few days. Would you like additional pain medication sent home? *

Yes, I accept additional pain medication to be sent home in case my pet is still painful for a few days ($15.00-$35.00 depending on medication and pet's weight) No, I decline additional pain medication for my pet

All dogs over 4 months of age are required to be vaccinated against rabies. Please choose one: *

I agree that my pet is current on their rabies vaccination I agree to have my pet vaccinated today ($22.75) I decline the rabies vaccine and accept all liability/responsibility

Please indicate any additional services you would like performed on your pet today.

Toenail trim (Complimentary) Anal gland expression ($20.00, if both glands are full) Ear cleaning ($26.50) Microchip implant ($59.00) E-collar or "cone" used to prevent licking: STRONGLY RECOMMENDED! ($10.50-$15.00 depending on size)

In the rare case of cardiac arrest (heart stopping), would you like us to attempt resuscitation, also known as CPR? (Please note that there will be an extra charge should we need to perform CPR on your pet.) *

Yes, please exhaust all efforts to try to resuscitate my pet. No, Please DO NOT RESUSCITATE.

If parasites (fleas, ticks, ear mites, intestinal parasites, etc.) are found on your pet we will treat at the owner’s expense for the protection of your pet and others.

Clients who are having their female pet spayed should be aware that if she is pregnant, the puppies or kittens will be aborted during the surgery. There is an additional charge for spaying a pregnant animal or an animal that is in heat.

If your puppy or kitten has persistent (baby) teeth that have not fallen out on their own, they will be removed for a fee of $12.00 per tooth plus a flat rate of $47.00 for additional anesthesia. (Failure to extract these teeth will cause excessive tartar and overcrowding of adult teeth.)

Though complications are rare, there is inherent risk in surgery and general anesthesia and sedation. Companion Animal Clinic cannot be held responsible for any reactions your pet may have to these medications.

By signing below you are giving consent to the staff and veterinarians of Companion Animal Clinic to anesthetize and perform the previously listed procedures (unless specifically declined) and acknowledge that you understand the special notes explained. By signing below you also agree to indemnify and hold the staff and veterinarians of Companion Animal Clinic free from and against any and all liability that may arise out of the performance of any of the procedures referred to above.

By signing below you certify that you are the owner or authorized agent for the above named animal and that you are responsible for him/her and have the authority to execute this consent.

By signing below you agree that you are responsible for payment in full of all above mentioned procedures and treatments at the time the patient is discharged.

We will make every effort to reach you should questions or problems arise, however, by signing this form you authorize the doctor to treat your pet as deemed necessary should he/she be unable to contact you at the number(s) provided. You also understand that veterinary staff will not be on premises 24 hours a day.

If you miss this appointment without calling Companion Animal Clinic to inform them ahead of time, you will be charged a $25.00 deposit if you want to schedule another appointment. That $25.00 will be deducted from your invoice balance on the day of the new appointment. If you miss the new appointment without letting CAC know ahead of time, the deposit is nonrefundable.

I have read and understand ALL of the above information.

Today's Date *

Date

Signature *

Clear