New East Holland Veterinary Clinic- Surgical consent form

East Holland Veterinary Clinic

Surgical Consent Authorization
Client Information*

First NameLast Name
Patient Information*
Please enter patient's first and last name (ie Fluffy Smith)
PREPARING YOUR PET FOR SURGERY

Fasting; In order to help your pet from feeling nauseated from the anesthetic agents, please withhold food after 10pm the night before the scheduled procedure, water can be left out.

Exotic patient Fasting; Fasting is NOT recommended for exotic patients. Please bring their favorite snacks with them for the procedure.

Surgical Check-in time is between 7:45am and 8:00am. If you can not make this time, please call us to set up other arrangements. One option is to drop your pet off the night before.

Medications; Before the procedure, ask your veterinarian if you can give medications in the morning- some may be needed, but some can be skipped.

The staff may need to contact you before, during or after your pets procedure. Please make sure to leave us a reliable phone number so that you can be reached easily at any time.
Dental Prophylaxis Include

*** This portion only required to be completed for Dental Procedures*** Pre-anesthetic lab work, Pre-Surgical Exam, IV catheter & IV Fluids, Anesthetic medications & Anesthetic monitoring, Ultrasonic scaling, Full Mouth digital X-rays, Pain therapy including a therapeutic laser. The veterinarian will evaluate dental x-rays and oral cavity and make recommendations according to findings.
Dental Prophylaxis- Grade 1-2 Dental= $480-$680, Grade 3 Dental= $800-$1100 & Grade 4 and above= $900-$1300 ***Dental procedures greater than Grade 2 include oral surgery in the estimation. Our intention is not surprise anyone with the cost of dentistry for their pet. Dentistry is very hard to estimate prior to the procedure. If desired the DVM can call to discuss the recommendations and work together to provide the best treatment plan for both the patient and owners.***
Extract teeth as recommended by veterinarian (Additional Fees will apply)Do not extract any teeth without my permission- If unable to be reached your pet will be woken up from anesthesia without extractions performed. An additional anesthetic procedure will be necessary to extract teeth.
Surgical Procedures Include

Pre-Anesthetic lab work, Pre-surgical exam, IV catheter & IV Fluids, Anesthetic medications & Anesthetic monitoring, Pain therapy including a therapeutic laser; Declaws will also receive local pain control(nerve block) & special litter
Canine Spay $460-590Canine Neuter $430-500Feline Spay $430-470Feline Neuter $300-3252 paw Declaw $400-4604 paw Declaw $550-630Feline Spay w/ 2 paw declaw $610-640Feline Spay w/ 4 paw declaw $640-685Feline Neuter w/ 2 paw declaw $580-630Feline Neuter w/ 4 paw declaw $630-660Growth/Mass removal- Timed procedureOther
Microchip implant ($49.00- includes chip implant & 1st year registration fee)No optional services
Please update vaccines as requiredI would like to discuss at time of drop off
YesNoCall 1st
Authorize CPRDo Not perform CPR
Signature*

Clear
I agree to be held financially responsible for veterinary services provided to my pet while staff pursue treatment and try to reach me for further directions. Regardless of my pet's recovery or survival, I agree to pay CPR fees in addition to other fees already identified by the practice and agreed upon by me.
Vectra 3DCredelioSerestoCategoSimparica TrioAll set on Flea/Tick
Qty requested today
HeartgardInterceptor PlusSimparica TrioAll set on Heartworm prevention
Qty Requested today
Comments, Please add any additional concerns to be addressed.
I will be the individual dropping off my pet the morning of the procedure.I will NOT be the individual dropping off my pet. Please do not do anything additional without my verbal consentI will NOT be the individual dropping off my pet. I authorize the individual dropping off to make financial decisions on my behalf.
Signature*

Clear
I understand that I assume full financial responsibility for all services rendered and that payment is due on the date of procedure. I am aware that any quote given is an estimate of incurred fees and while every effort will be made to stay within those guidelines, we cannot always anticipate additional charges which may occur.
Please leave a good phone # that you will be available at while your pet stays with us.*

Area CodePhone Number
If you have any questions or concerns please contact the clinic @ 616-392-1835.
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East Holland Veterinary Clinic

Dental Prophylaxis Include

Surgical Procedures Include