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?*

Yes, I give my permission to perform CPR and other life-sustaining measures and understand I am responsible for the cost of these procedures (additional cost applies).No, I do NOT give my permission to perform life-sustaining measures (Do Not Resuscitate).

Would you like your cat FeLV/FIV/HW tested? Cost $125.00

YesNoAlready tested

Has your cat had any previous surgeries?*

NoSpay / NeuterDentalOther

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.

YesNo

A microchip can be inserted under the skin between the shoulder blades to aid in recovery and identification of a lost or stolen pet. 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*

Yes, please insert a microchip while my pet is asleep.No, I do not want my pet microchipped today.My pet is already microchipped. Please check my pet's chip today.

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.*

Toe nail trim $30 + taxNail caps applied (front only) $75 + taxTattoo (Spay only) $27No additional services

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*

I authorize The Feline Medical Center to perform all necessary surgical procedure(s) to my pet.I understand the risk and complications if I do not follow the instructions given to me after the procedure which involves post-treatment instructions and follow-ups as needed.I release The Feline Medical Center for any responsibility in case of an accident, illness, or injury.

Owner Release*

I assume full responsibility for any additional expenses incurred before, during, and after the surgical procedure is performed, such as progress exams, radiographs and/or additional surgery due to additional findings and/or post-op complications.I understand that if I no-show for the scheduled surgical procedure or cancel less than 48 hours prior to the scheduled surgical procedure, I will incur an additional fee of $100.00.

Client/Agent Signature*

Date Signed*

Date

Feline Surgical Consent Form

Medical Data

Acknowledgment & Authorization