Surgical Consent Pre-Registration

Surgical Consent Pre-Registration

Marshall Animal Clinic
How to fill out your surgical consent form with Dr. Westegaard
Name*

First NameLast Name
Pet's Name*
Date of Procedure*

MonthDayYear
Date
Phone Number that we can reach you at during surgery*
Please enter a valid phone number.Format: (000) 000-0000.
How do you wish to be contacted after your pet is done with surgery?*

CallTextEmail
Email*
example@example.com
Please choose which procedure:*

SpayNeuterDentalTumor RemovalOther
Is your pet on any medications? If so, when did they get their last dose?*
Pre-Anesthetic Blood Testing-Before putting your pet under anesthesia, we perform blood screening to detect many conditions including liver, kidney and blood disorders that would otherwise go undetected. ** PRE-ANESTHETIC BLOODWORK IS STRONGLY RECOMMENDED FOR: GERIATRIC PATIENTS, DENTAL PROCEDURES, ABDOMINAL SURGERIES (ex. SPAY), ETC. (Cost:**$115-$170)*

Yes, please complete blood work on my pet for an additional $115-$170..No, I do not wish to have bloodwork completed on my pet and I understand that this may increase the risk of unforeseen complications.
Please sign below ONLY if you have declined bloodwork.
IV Anesthesia Catheter - IV catheter and intravenous fluid therapy to help maintain normal blood pressure during surgery. **This does not apply to cat neuters & declaws, please select NO***

Yes, I wish to have the IV Anesthesia Catheter placed for an additional $48.00.No, I do not wish to have the IV Anesthesia Catheter placed.
Microchip: Microchips provide the peace of mind that you have given your pet a permanent ID. The simple and safe procedure is only $49.98 for the microchip and registration.*

Yes, I wish to have a microchip placed.No, I do not wish to have a microchip.
Preventative Dental Radiographs: If your pet qualifies for a preventative dental, you may choose to add on dental radiographs. We recommend baseline radiographs on all pets. In some cases, this may not be optional depending on the condition of your pet's teeth.*

Yes, I wish to have dental radiographs done on my pet ($97.50).No, I do not wish to have dental radiographs done on my pet.
Misc. Services:*

Pedicure (Complimentary)Extractions (If your pet is scheduled for a dental procedure)Anal glands ($19.45)Update VaccinationsHeartworm Test ($48.45)E - collar (Cone $11.00)No additional services neededOther
If you chose any of the Misc. Services above please specify how many preventative doses or what vaccines you wish to have completed.
Do you need any preventatives (flea/tick or heartworm) for your pet?

YesNo, my pet is protected.
If you chose yes, please list what preventative you need and how many:
If your pet is known to be anxious, fearful or aggressive at the clinic, please let us know and we will arrange for you to pick pre-visit medications for you administer at home. This consists of a combination of pain and anti-anxiety medications to be given the night before and the morning of surgery.*

Yes, my pet is anxious.No, my pet is not anxious.
Payment Method: Please choose how you wish to pay for the procedure. We require half down when you drop off your pet in the morning and the remaining balance at pick up.*

Secure Texted LinkCardCashCheckCare CreditScratch Pay
Please be sure to bring your dog on a leash or cat in a carrier.

All cats without carriers will be sent home in a cardboard carrier ($11.50) to ensure their safety.
I am the owner or agent for the above described animal and have authority to execute this consent. I hereby authorize the above procedures. I understand that there are always potential risks when using anesthesia or performing surgery on an animal including death. I understand that the use of anesthetic agents and/or pharmaceuticals could result in unforeseen complications. No guarantee or assurance has been given as to the results that may be obtained. I further agree that Marshall Animal Clinic, Veterinarians and other staff shall be held harmless from liability for all matters consented to and authorized herein. I assume full responsibility for these decisions. I understand that payment is expected at the time of service. I have read and fully understand this consent.
Signature*
Date*

MonthDayYear
Date
Should be Empty:

Surgical Consent Pre-Registration

Please be sure to bring your dog on a leash or cat in a carrier.