Surgery/Dental Consent Form

Surgical/Dental Consent Form
Pet Details
Your Name*

First NameLast Name
I will be the person dropping off my pet the morning of the procedure:*

YesNo
Pet's Name *
Pet's Name
Email*
example@example.com
Phone Number where you can be reached AT ALL TIMES the day of the procedure*
Please enter a valid phone number.Format: (000) 000-0000.
Date of procedure*

MonthDayYear
Type of procedure*
Your pet should be fasted (not given food) after 9pm the night before the procedure. Water is OK and should not be restricted
*

Yes, I undertand and have fasted my pet
Pet Medical History
Are there any health concerns with your pet that you would like our veterinary team to address? (ear infection, lameness, etc)*
Do you give permission for our staff to treat the concerns listed above?*

YesNo
Please list all medication or supplements your pet is taking - Please include the name of medication, dosage, and when it was last given.*
Has your pet shown recent signs of illness such as vomiting, diarrhea, coughing or sneezing?*

YesNo
If yes, please describe
Has your pet shown any changes in appetite, drinking or exercise habits?*

YesNo
If yes, please describe
Please list any behavioral or handling concerns (fear biting, dog aggression, pain etc):*
Would you like your pet microchipped at the time of the procedure?

Yes, please microchip my petNo, do not microchip my pet
The order of procedures will be triaged the morning of the procedure, with the most critical patients receiving intervention earliest in the day. I understand that my pet's procedure may be later in the day and the staff will call me when the procedure is complete.*

I understand
Post Operative Care
Pain Control*

I prefer giving oral tablet medicationsI prefer giving oral liquid medicationsI am unable to give ANY oral medication
Additional Sedation

I am concerned I may have difficulty keeping my pet calm after the procedure. I request additional sedatives to give if needed for the duration of recovery (likely 10 days)
Additional Information
I have received an estimate for the procedure and understand that payment is due at the time of service*

Yes, I have received an estimate for the procedureNo, I have not received an estimate for the procedure
By signing below, I certify that I am the owner or agent of the owner of the above named pet and I have the authority to make medical decisions related to the pet. I authorize the Devon Veterinary Staff to provide care and perform any treatment they consider reasonable and necessary for my pet.

I understand that payment in full is required at the time of service. DVH will provide an estimate of fees upon my request. I acknowledge that an estimate is only an approximation; actual fees may vary. I recognize that I am responsible for all charges related to my pet.
I understand that risks exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure in initiated.
Signature*
Should be Empty:

Surgical/Dental Consent Form

Pet Details

Pet Medical History

Post Operative Care

Additional Information