Spay/ Neuter Pre- Surgery Form

Spay/ Neuter Pre- Surgery Form
What you need to Know Prior to Surgery

FASTING

Your pet can have dinner at their usual time the night before the surgery. Please also feed your pet ¼ of their usual meal again at 10 p.m. DO NOT feed your pet the morning of surgery, if we find that your pet has been fed we will be unable to proceed with surgery. Give their Cerenia dose between 6a.m. and 7a.m. the morning of surgery. This medication is included with all of our surgical procedures – if you have not received this dose, please contact our office. Water can be given freely until your pet is admitted for surgery.

ADMISSION TIMES

An intake appointment has been scheduled for you and your pet the morning of surgery. This appointment will take place with a registered veterinary technician and will be approximately 10 minutes long.

THE DAY OF THE SURGERY

One of our registered veterinary technicians will contact you throughout the day of the surgery to let you know how your pet is doing. If you wish, any inquiries about your account can be done at this time.

DISCHARGE TIMES

Your pet will be able to go home after 4 p.m. the day of the surgery, provided there are no concerns or cause to keep him/her longer. A discharge time will be booked after your pet’s surgery when our registered veterinary technician contacts you.

PAYMENT DETAILS

A treatment plan will be provided to you prior to your pet’s surgery, if you have yet to receive this please contact our office. Full payment will be required at the time of discharge. In the case of non-payment, a finance charge of 12% per month will be charged and any service charges, collection fees or attorney fees will be paid by you, the owner.

* Details regarding post-surgical care will be made available to you at the time of discharge *

CLIENT INFORMATION
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contacts on Account

Please list contact names that will have permissions on the patient's account. These individuals will be able to make any and all decisions that can impact the health of the patient. They can not be removed off of the file without written consent from other owners listed on the account.
List Any Contact that Should be on the Account?*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com

PATIENT INFORMATION
Pet Name*
Pet Species*
Pet Breed*
Pet Colour*
Pet Sex*

MaleFemale
Pet's Date of Birth (or approximate age)*
Insurance Company Name (if applicable)
Any Concerns/ Health Issues?

ANESTHETIC INFORMATION & CONSENT
Procedure to be Preformed? (Spay or Neuter)*
I, the undersigned do certify that I am the owner/authorized agent of the animal described above and have the authority to complete this consent form. I do hereby consent and authorize Pine Grove Veterinary Hospital, its staff and/or authorized agents to: hospitalize; administer any necessary medications; perform any necessary diagnostic tests/procedures/treatments and carry out any sedation/anesthetics that the doctors deem necessary for the health, safety or well-being of the animal described above while he/she is in their care and supervision.

I understand the nature of the procedure(s) being carried out and the risks associated with performing general anesthesia, up to and including death. I realize that results cannot be guaranteed, and I do understand that all reasonable precautions will be taken for my pet’s health and safety. If my pet should injure itself in an escape attempt; refuse food; soil itself; become ill or die while in the hospital, I will hold Pine Grove Veterinary Hospital and its staff free of any responsibility and/or liability in the absence of gross negligence.

I further realize that I am responsible for payment for the following procedure(s) and treatments in full at the time my pet is discharged. If I neglect to pick my pet up within five (5) days of written notice that he/she is ready for release (mailed to the above address,) you may assume that he/she is abandoned. You are then authorized to proceed with him/her in whichever way you see fit. Abandonment does not release me of my financial obligation concerning the bill.

I understand that if my pet is found to have fleas that he/she will be treated with the product “Advantage” and I will be billed accordingly. If I choose to purchase the remainder of the package it will be made available to me at the time of discharge.

I acknowledge that my pet will have the following done either prior to or on the day of surgery:

- Pre-anesthetic blood work - my pet will have a blood sample taken to assess the following:

- Complete Blood Count: assesses white blood cells, red blood cells and platelets;

- Biochemistry Profile: assesses liver, kidneys, pancreas, electrolytes, proteins and glucose;

- I.V. fluids during the procedure and recovery period - IV fluids help to maintain blood pressure; help to flush the medications/anesthetics given through the liver and kidneys as well as providing IV access in cases of emergency;

- pain medication and;

- post-operative support from one of our registered veterinary technicians

IN CASE OF AN EMERGENCY
In case of an emergency, it is important that we are able to contact you IMMEDIATELY, PLEASE ensure you stay close to your phone. An emergency contact or alternative contact MUST be an individual whose name is on the patient’s file and has informed consent to make decisions on behalf of the patient.
Main Contact Name*

First NameLast Name
Main Contact Phone Number*
Please enter a valid phone number.
Additional Contact Number for Main Contact
Please enter a valid phone number.
Alternative Emergency Contact Information: This individual MUST NOT be on the patient’s file and have informed consent to make medical and financial decisions on behalf of the patient in the event the MAIN CONTACT can not be reached.
Alternative Contact Name (Must NOT be Named on Patient's File)*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Emergency Procedure Options

If we are unable to reach you at the given contact number(s) above, we need consent before surgery on how you would like Pine Grove Veterinary Hospital Staff to proceed in the event of a lifesaving situation; please select the option that aligns with you would like our staff to proceed:
Resuscitate my Pet - I give Pine Grove Veterinary Hospital staff permission to complete any medically necessary procedures to preserve my pet's health in the event of a lifesaving situation. Furthermore, I agree to pay the additional associated costs, which can begin at $500 and increase depending on the circumstances.*

I GIVE PERMISSION to Resuscitate my Pet - complete any procedure deemed medically necessary, starting at $500.I DECLINE to Resuscitate my Pet - I understand that this decision may affect the recovery and future health of my pet.
DNR - Do Not Resuscitate my Pet - I wish Pine Grove Veterinary Hospital to only perform the agreed-upon procedure. In the event of an emergency, I do not want any other veterinary medical care given to my pet without my permission, even if it to preserve my pet's health or in the event of a lifesaving situation. I understand that this may mean another anesthetic and/or surgical procedure could be required later. I also understand that this decision may affect the recovery of life and future health of my pet.*

I GIVE PERMISSION FOR - DNR - Do Not Resuscitate my Pet Status - only perform the agreed upon procedure.I DECLINE a DNR - Do Not Resuscitate my Pet Status – I want ANY procedures deemed medically necessary, starting at $500.

CONSENT and SIGNATURES
By signing I acknowledge that I have read, understand and filled out all information on this Pre-Surgical Form to the best of my knowledge and give full consent for Pine Grove Veterinary Hospital to proceed with the procedure outlined on this form.
Signature*

Clear
Date Signed*

MonthDayYear
Date
By submitting this form, I agree to the Privacy Policy and consent to the processing of my personal data as described therein.
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Spay/ Neuter Pre- Surgery Form

What you need to Know Prior to Surgery

FASTING

CLIENT INFORMATION

Contacts on Account

PATIENT INFORMATION

ANESTHETIC INFORMATION & CONSENT

IN CASE OF AN EMERGENCY

Emergency Procedure Options

ADDITIONAL SURGICAL OPTIONS

CONSENT and SIGNATURES