Companion Animal Hospital Surgery / Dental Form

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

First NameLast 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 CodePhone Number
Dental / Surgical Procedure*
Would you like a microchip implanted while your pet is sedated?*

YesNo
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*

YesNo
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.*

YesNo
I want the following blood screen done on my pet:*

Chem 10/ cbc (Under 7 years old) $140.00Chem 17/ cbc (7 years and older) $150.00My 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*

YesNoN/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.
Dental radiography is not available at this facility. Should the veterinarian identify concerns that require dental radiography to further evaluate, a referral will be recommended.*

I understand
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 Surgery / Dental Form

Fasting for Surgery

Cerenia Pre Surgery Injection

Pre- Anesthetic Blood Screening