FMC- Feline SURGICAL Consent Form

Client's Name

First NameLast Name

Email

example@example.com

Phone number where you can be reached day of surgery.

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cat's Name

Breed

Color

Sex

Female/Spayed/Male/Neutered

Weight (LB)

Surgical procedure(s) to be performed:

When was food last given?

I, the undersigned owner or agent of the cat identified above, authorize the staff of The Feline Medical Center to perform the above procedures.

I understand that some risk always exists 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(s) is/are initiated.

In the case of unforeseen emergencies, does the staff have your permission to proceed with life sustaining procedures?

Would you like your cat FeLV/FIV/HW tested? Cost $130.00

Has your cat had any previous surgeries?

Other

Has your cat shown any signs of illness in the last 2 weeks? If yes, please explain

Is your cat currently taking medications? If yes, please list all medications including dosages.

I approve use of photos of my cat for educational or social media purposes when appropriate.

A microchip can be inserted under the skin between the shoulder blades to aid in recovery and identification of a lost or stolen pet. Our microchips will read core body temperatures with a compatible scanner, reducing the need for rectal temperatures in-clinic. The cost is $102.00 and includes the lifetime registration of the chip. The microchip will automatically register with your account details on file.

Microchip

Optional Additional Services to be performed while your pet is under anesthesia. Please select any and all optional services that you would like performed- additional cost applies.

The Feline Medical Center is a parasite free facility. If fleas or other parasites are found on your pet today, they will be treated as deemed appropriate by the doctor. Treatments will be given at the owner's expense and are in addition to any other services performed today.

I have read this consent form in its entirety. While I accept that all procedures will be performed to the best of the abilities of the hospital staff, I understand that no guarantee or warranty has been made regarding the results that may be achieved.

Authorizations and Acknowledgment

Owner Release

Client/Agent Signature

Date Signed

Date

Feline Surgical Consent Form

Medical Data

Acknowledgment & Authorization