Surgery Consent Form
Please fill out this form in entirety to ensure we can provide your pet with the best possible care.
Pet's Name
*
First Name
Last Name
Your Name
*
First Name
Last Name
Email
example@example.com
Where can we call you at while your pet is here?
*
-
Area Code
Phone Number
Is there anyone else we can call regarding your pet while they are here today?
Yes
No
Alternative Contact Name
*
First Name
Last Name
Alternative Contact Phone
*
-
Area Code
Phone Number
Reason for your pets visit today?
Please list type of surgery. For example: lump removal, cystotomy, etc.
Has your pet had any food since midnight last night?
Yes
No
Unsure
Has your pet been vomiting or having diarrhea?
Yes
No
Unsure
If yes, please describe/provide more information
Has your pet ever had any adverse reaction to medication?
Yes
No
Unsure
If yes, please describe/provide more information
Please list any medications, supplements, topical treatments your pet has received in the past 72 hours and when they were last given:
I authorize the use of appropriate anesthetics and other medications. I understand that anesthesia does present a risk to my pet's life, and I accept that risk as a part of the procedure(s).
*
I understand and accept
*Only applicable if your pet is getting a lump or tumor removed. We recommend histopathology on all lumps or tumors removes in order to identify the type of tumor and level of aggressiveness. These results typically take about 5 - 7 days to get back. (Additional Fees Apply)
Yes, I would like the mass sent off for histopathology. $201.55
No, I do not authorize histopathology
Is There Anything Else We Should Know About Your Pet?
If yes, please tell us more. If no, please note N/A
Authorizations
I verify that I am the owner (or authorized agent for the owner) of the above named pet and authorize treatment of my pet to be performed by South Tampa Veterinary Care. I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure as directed by the veterinarian. I have been advised as to the nature of this procedure to be performed and the risks involved. No guarantees have been made regarding the outcome or cure. I understand that there is always a risk associated with any sedation or anesthesia episode, even in apparently healthy animals, and have discussed my concerns with the veterinarian. The veterinarian has provided me the opportunity to ask questions and receive answers regarding the procedure. This risk includes serious bodily injury or death. I understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated for the safety or care of my pet. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian’s professional judgment. I accept responsibility for any result in additional charges.
*
Initial
I agree to be responsible for all charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital. I understand no staff will be attending to my pet overnight (pets needing special care may be referred to a 24 hour hospital).
*
Initial
*
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