Surgical Anesthetic Treatment Form

Surgical Anesthetic Treatment Form
Please fill out all of the required form fields below. Your submission will autopopulate a PDF which will be sent to our staff for review.

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Date

MonthDayYear
Date
Pet Name*
Pet Owner Name*

First NameLast Name
Procedure Name*
Today’s Weight (If known)
Vaccination Initials*
Rabies is required for all patients undergoing treatment. I understand this requirement and authorize vaccination of my pet if he/she is due for Rabies.
Bloodwork Initials
Pre-anesthetic blood for patients under the age of 7 years is optional ($77.60) Cost of pre-anesthetic blood work is built into the estimate for patients over the age of 7 years. I understand these conditions and approve of pre-anesthetic blood work for my pet.
Person Signed: (Owner of animal or authorized agent)*
Date Signed*

MonthDayYear
Date
Phone Number where you can be contacted*

Area CodePhone Number
Pet Food/Water Initials*
Please initial if the pet has had no food or water for the past 10 hours
Procedure Estimate Initials*
Please initial if you have received an estimate for the procedure and approve the treatement listed
Authorization to Treat Initials*
For the health and safety of all of our patients, any animal on premises with signs of fleas will be treated at owners expense.
Please check if you would like any from the list below.

Microchip-Home Again (includes Registration) - $57.50Standard Nail Trim - $13.50Dremel - $ 25.50Standard Ear Cleaning - $18.70Anal Glands Expression: $18.20Face Trim - $18.20
Number of baby teeth to be extracted (If applicable)
If the pet is having baby teeth extracted please input the number of deciduous teeth (baby teeth) being extracted ($29.03 per tooth)
Do you give permission for baby teeth to be extracted? (Choose only if the pet is having teeth extracted)

Approve ExtractionDecline Extraction
Retained Testicle Initials (If applicable)
I am aware that my puppy has a retained testicle, this may require an additional incision(s). There is an additional fee of $102.86. I give permission for my doctor to perform the additional procedure
Should be Empty:

Surgical Anesthetic Treatment Form

Please preview form before submitting.