Surgical Consent Form

Surgical 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 NameLast Name
Your Name*

First NameLast Name
The date your pet is scheduled for surgery

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
It is imperative that we are able to reach you in a timely manner while your pet is with us today. Please list your preferred contact number and be available.
Phone for today:*

Area CodePhone Number
Reason for your pets surgical visit today?*
Do you want your pet to receive a Homeagain microchip today? The cost is $57.00*

YesNoCan you scan to see if my pet has one? If my pet doesn't please give him/her a microchip.
Fasting surgical guidelines: Please read and check what applies to your pet: If you have any questions or concerns please contact us for direct guidelines for your pet.*

I have dog or cat with no current chronic daily medications. Fasting guidelines: no food past midnight the night before your pet's surgical procedure. Water can still be offered.I have a cat or dog on chronic morning medication(s)- Give medication as directed in a VERY small amount of food/ treat the morning of surgery.I have a diabetic dog or cat. Give 1/2 dose of your pet's insulin at the regularly scheduled time the morning of surgery. Bring your pet's insulin and syringe with you the morning of surgery in case we have to administer any insulin at the clinic.I have a rabbit, guinea pig, hamster, mouse or rat. No fasting required. Please make sure your pet continues to eat and drink. Bring your pet's travel cage/ carrier, food and water with you when you bring your pet. If you are bringing multiple pet's please bring each pet in a separate travel carrier.
Has your pet been experiencing any vomiting or diarrhea?*

YesNoUnsure
Does your pet have any allergies?*

YesNoUnsure
Please describe/provide more information
Has your pet ever had any adverse reaction to medication?*

YesNoUnsure
Please describe/provide more information
Please list any medications, supplements, topical treatments your pet has received in the past 72 hours from the scheduled surgical day and when they were last given:
When Was Your Pet's Last Dose of Flea/Tick Preventative?
Date Given (Please type N/A if not on a preventative)
What Kind of Flea/Tick Preventative Do You Use?
Name of medication - put unknown if not sure
Is Your Pet Current On Vaccinations?

YesNoI Am Not Sure
My pet's vaccines were administered last by:

At Aurora Veterinary Clinic, Streetsboro Veterinary Center or Mantua Veterinary ClinicI Am Not Sure WhereOther
Blood Work: If not current for your pet's age or medical condition, will be performed the morning of surgery. *

Yes, I am aware that my pet's blood work (evaluating liver values, kidney values, and blood count) will be run if values are not current.
In the event that I cannot be reached during the procedure and do not return the phone call or text within 10 minutes:*

I authorize the doctor to proceed with any recommended treatments without verbal permission.I understand my pet will be recovered. If I decide to pursue recommended treatments, they will be performed at a later date and time with additional costs associated.
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 Aurora Veterinary Clinic, Streetsboro Veterinary Center or Mantua Veterinary Clinic. 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.*
Initial
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 anesthetic 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. Should overnight care and monitoring be warranted, I understand that I will be referred to a 24 hour hospital *
Initial
In the event of an unforeseen emergency, we will attempt to reach you immediately. Please know that we will take every precaution to ensure that your pet is safe and healthy enough to undergo their procedure today. Any known risks will be discussed with you. However, very rarely, emergencies do happen and we need to know your preference if no one can be reached. Please check your preference:*

Please proceed with basic cardiopulmonary resuscitation (CPR). I accept responsibility for all costs incurredPlease do not proceed with basic cardiopulmonary resuscitation (CPR).
I acknowledge my choice regarding resuscitation choice for my pet as noted above.
Initial
Signature*
**Please leave this text portion blank because a staff member will ask you the following questions the morning of your pet's surgical admit***
Procedure verified: Verified name of Person to phone number to call: When did patient eat last: If Patient is currently taking medications list names at what day/time did patient have them last: If patient is a canine and getting spayed, when was their last known heat cycle: Changes in urinations/drinking/vomiting or diarrhea over the last 24 hours: Belongings brought with patient today: Any additional questions or notations: Completed by:
Should be Empty:

Surgical Consent Form

Authorizations