Pre-Surgical Consent Form

Pre-Surgical Consent Form

South Rhea Animal Hospital | 865 Rhea County Hwy | Dayton, TN 37321
Full Name*

First NameLast Name
Pet's Name(s) *
Today's Phone Number*
Please enter a valid phone number.
Evening Phone Number*
Please enter a valid phone number.
As owner or agent of the above animal, I hereby give my consent to SOUTH RHEA ANIMAL HOSPITAL to perform the following procedures: List procedure(s)

I understand that during the performance of this procedure, unforeseen conditions may be revealed that necessitate an extension or variance in the procedure(s) set forth above. I expect SOUTH RHEA ANIMAL HOSPITAL to use reasonable care in judgment in performing the procedure(s). The nature of the procedure and risks involved have been explained to me and I realize results cannot be guaranteed. I am also aware that unforeseen events resulting from procedure(s) will not relieve me from any obligation to all reasonable costs incurred regarding the animal.
LABORATORY TEST WAIVER

If your pet is to be anesthetized, rest assured that advances in anesthesia and surgery have made routine procedures relatively safe with a low rate of complications. Nevertheless, occasional problems can arise due to pre-existing conditions not evident during routine pre-anesthetic examinations. To avoid these problems, we recommend that all of these cases be screened prior to anesthesia by means of the following laboratory tests.

Initial for Consent to Perform (additional costs):
Initial for consent A. White Blood Cell Count, Packed Cell Volume, Blood Clotting Time, Liver/Kidney Evaluation, EKG
Initial for consent B. Pain Management Injection
Initial for consent C. Take-home Pain Medicine
ADDITIONAL SERVICES

Please note any additional services that you would like us to perform while your pet is anesthetized:
Please list all additional services
ALL ANIMALS ADMITTED MUST BE CURRENT ON RABIES VACCINATIONS AND MUST BE FREE OF EXTERNAL PARASITES. ANY ANIMAL FOUND TO HAVE FLEAS OR TICKS BEFORE PROCEDURE WILL BE TREATED AT THE OWNER'S EXPENSE. IT WILL BE AN ADDITIONAL CHARGE FOR ANIMALS THAT ARE SPAYED WHILE PREGNANT OR IN HEAT.
Technician signature, printed name, and date Technician Signature

Owner/Agent signature, printed name, and date Signature of Owner/Agent
Should be Empty: