Companion Animal Hospital (Dog) Surgery / Dental Form

Companion Animal Hospital (Dog) Surgery / Dental Form
Pet's Name *
Owners Name *

First Name Last Name
Dental / Surgical Procedure *
Fasting for Surgery
When did pet last eat? *
What medications is your pet taking? *
When was medications last administered? *
General Information
Is your pet up to date on vaccines? (Rabies, Distemper and Bordetella) *

Yes No
Heartworm test within last year? *

Yes No
Need Heartworm test today? *

Yes No
Need Fecal today? *

Yes No
Need Heartworm / Flea Prevention? *

Yes No
Need Influenza Vaccine today? *

Yes No
Pre- Anesthetic Blood Screening

***(Required for Pets 5 years and older)*** Blood screens alert doctors to any potential health problems while ensuring that your pet is healthy enough for anesthesia / surgery
My pet is under 5 years old and I want a blood screening. *

Yes No
I want the following blood screen done on my pet: *

Chem 10/ cbc (5-7 years old) $110.00 Chem 17/ cbc (8 years and older) $117.00 My pet is less than 5 years old and I do not want a blood test.
Consent for Extraction *

Please do whatever is needed. Please do whatever is needed up to amount authorized. Please call me first for any additional treatment. Please do nothing more than I have authorized.
If authorizing a certain amount for "Consent for Extraction" please fill in amount below.
Authorization to proceed

1) I authorize the use of appropriate anesthesia/medication and support the personal judgement of the Veterinarian. I understand even though every precaution is taken, anytime an animal is anesthetized there is a slight risk that an adverse reation could potentially occur resulting in death.

2) I understand during the above listed procedures an unforseen medical condition may become evident that necessitates an extension of or an addition to these procedures. I authorize the performance of such procedures as are perceived necessary in the professional judgement of the Veterinarian.

3) I understand that the result of any procedures/surgery can not be guaranteed.
I am aware of the risks and understand the information presented in this consent form and I give authorization to proceed with procedures/surgery and perform any and all life saving procedures should the need arise. (By filling in your complete name below, it is legally binding just as your personal signature.) *
Should be Empty:

Companion Animal Hospital (Dog) Surgery / Dental Form

Fasting for Surgery

General Information

Pre- Anesthetic Blood Screening