Surgical Consent Form

Owners Name*

First NameLast Name

Phone number where you can be reached during the scheduled surgical procedure:*

Patient Name*

First NameLast Name

What procedure(s) is your pet coming in for?*

Please select the elective services you would like performed:

Pre-anesthetic Laboratory Evaluation: $175 (patients under 7 years old) $205 (patients over 7 years old) *Bloodwork is required for all patients over 7 years old or at the doctors discretion when deemed necessary.*Sedatives (to go home): In order to help recovery, it is important that your pet stays calm and rested following surgery.To keep your pet calmer during this recuperation period, we can send home some sedatives. ($TBD)Elizabethan Collar. This is the lam-shade looking device that goes on your pets neck to help prevent licking/chewing of the surgery site. We strongly recommend you taking one, unless you have one at home. $15Canine Heartworm Test: $47 (Heartworm testing should be done annually for all dogs over 1 year of age.)Intestinal Parasite Screening: $32 (Intestinal parasite screening should be done annually for all pets.)Home Again Microchip: $55Nail Trim: Complementary

CPR: In the event that your pet should experience cardiac or respiratory arrest while being hospitalized today, do you give consent for resuscitative efforts to be initiated until you can be contacted further and notified of your pets status? By consenting to this service, you are also acknowledging that certain fees will apply. If you are not able to be contacted immediately, resuscitation efforts will be continued to be performed at the doctor’s discretion. Please select your choice below.

I agree to CPR being performed in case of arrestI elect a “Do Not Resuscitate” status in case of arrest

Does your pet have any allergies?*

YesNoNot Sure

If yes, please tell us below what allergies your pet may have.

Is your pet currently taking any medications?*

YesNo

If yes, please tell us below what medications your pet is taking and when the last dose was given:

All surgical patients must be up to date on vaccines. If your pet is past due for vaccines we will give the required vaccines at the time of thier surgical procedure.

Vaccine Requirements:

Canine - Rabies, DHPP, Bordetella and Fecal

Feline - Rabies, FVRCP

I hereby authorize anesthesia/surgery for my pet. I understand that some risks always exist with anesthesia and/or surgery. My signature on this consent form indicates that any questions have been answered to my satisfaction. While Hog Mountain Animal Hospital provides the highest quality of anesthesia monitoring and surgical services, I understand that there are rare complications associated with any anesthetic or surgical procedure. In particular, I have been advised that there is an extremely small risk of death, complications, or side effects every time an anesthetic is used and that I have been advised of the possibility. I acknowledge these risks and understand that the veterinarians and hospital staff will try to minimize such risks. I will not hold Hog Mountain Animal Hospital, the veterinarians, or any staff member liable for any Complications that may arise. Please select yes to indicate that you understand and agree with the above information.*

YesNo

By signing below you give Hog Mountain Animal Hospital consent to perform the above procedures and treatments.*

Anesthesia & Surgical Consent Form