Walnut Creek - Surgery Form

1

Owner/Pet Information

Owners Name

Pets Name

Best Contact Phone #

Last Food

Current medications and when last given:

Any symptoms of illness recently? (Examples: Vomiting, diarrhea, coughing or refusal to eat / drink)?

2

If YES for symptoms of illness, please describe them here:

3

Requested Procedures to be performed +$46.01 additional (spay) if pregnant/in heat

4

Pre-Anesthetic Laboratory Diagnostics: Lab work helps the veterinarian decide if a patient is healthy enough for anesthesia and if modifications need to be made to the protocol to make the procedure as safe as possible.

We strongly recommend pre-anesthetic laboratory diagnostics for all patients being sedated or placed under general anesthesia; however, this testing is not required for all patients.

I ACCEPT lab work at an additional cost of $123.70 I DECLINE lab work *

5

Please Specify* This field is required.I understand the risk that death may occur without life saving efforts.

I AGREE to allow life saving techniques to be performed on my pet. (CPR)

I do NOT want life saving techniques to be performed on my pet. (DNR)

6

Laser Therapy at Incision Site ($18.93)* This field is required.Cold laser therapy is a non-invasive procedure that uses light to stimulate cell regeneration and increase blood circulation to promote the healing process.

Yes

No

7

Microchip Implant $50.49* This field is required.This is not a GPS tracker.

Yes

No

8

Ovariohysterectomy (OHE, Spay): Once an animal is spayed, she is no longer able to become pregnant. If an animal is pregnant at the time a spay is performed, the pregnancy is terminated and the offspring will not be viable. By signing below, I am verifying that I understand that if my pet is found to be pregnant during surgery and I wish to proceed with surgery, the pregnancy will be terminated and the litter will not survive.

9

If pregnancy is discovered during surgery* This field is required.

I do wish for the veterinarian to proceed with the spay.

I do not wish for the veterinarian to proceed with the spay.

N/A for all the other Surgeries

10

I verify that I am the owner (or owner’s authorized agent) of the above-named pet and authorize the above outlined procedures to be performed. I further authorize the use of anesthesia and other medications as deemed necessary by the veterinarian and understand that other hospital personnel may be employed in the procedure(s) as directed by the veterinarian.

I have been advised as to the nature of the procedure(s) to be performed and the risks involved. I understand that there is always risk associated with anesthesia, even in apparently healthy animals. I have discussed my concerns, if any, with the veterinarian. I understand that it may be necessary to provide medical or surgical procedures which are not anticipated or outlined above for the safety and well-being of my pet. I accept responsibility for any additional charges that may be incurred by such measures and further understand that payment in full is due at the time my pet is discharged from the hospital.

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Signature * This field is required.

Clear

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Date * This field is required.

Date

13

Please enter your email if you would like a copy of this consent form sent to you.

example@example.com