Companion Animal Hospital Surgery / Dental Form

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

First Name Last Name
Phone Number you can be reached the day of surgery. (If we can not reach you for any non-emergency procedures, patient will be recovered from said procedure.) *

Area Code Phone Number
Dental / Surgical Procedure *
Fasting for Surgery
When did pet last eat? *
What medications is your pet taking? *
When was medications last administered? *
Cerenia Pre Surgery Injection

** We strongly recommend this for any pet undergoing anesthesia for a better recovery.
Would you like your pet to receive an injection before it's procedure that will help with post-surgical nausea, vomiting, inappetence, refusal of medication, restlessness and discomfort?

< 25lbs $35.00

26-50lbs $55.00

51-90lbs $65.00

> 91lbs $80.00
Please answer here for the Cerenia Pre Surgery Injection question above *

Yes No
Pre- Anesthetic Blood Screening

***(Required for Pets 7 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 7 years old and I want a blood screening. *

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

Chem 10/ cbc (Under 7 years old) $140.00 Chem 17/ cbc (7 years and older) $150.00 My pet is less than 7 years old and I do not want a blood test.
If your pet is coming in for a tumor removal, do you want a histopathology done on the mass? $180.00 *

Yes No N/A
Consent for Extraction *

Please do whatever is needed. Please do whatever is needed up to amount authorized below. Please call me first for any additional treatment. Please do nothing more than I have authorized. N/A
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.) *
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Companion Animal Hospital Surgery / Dental Form

Fasting for Surgery

Cerenia Pre Surgery Injection

Pre- Anesthetic Blood Screening