HVH Surgery Consent Form 2023

HILLSIDE VETERINARY HOSPITAL

191 Augustine Avenue Suite 100, Charles Town, WV 25414 // 304-728-2203
Surgery Consent Form
Client Name:
Last, First
Pet Name:
Date of Surgery:

MonthDayYear
Date of Surgery:
Address

Street Address

Street Address Line 2

CityState (abbreviation)

Postal / Zip Code
Email
example@example.com
Feline/ Canine?
IndoorOutdoorIndoor/Outdoor
Breed:
Sex:
female/ male and spayed/ neutered
Color:
Birthdate/Age:
What is the Surgery/Procedure Being Performed Today? (for tumor removals, please give exact # of tumors we are removing and specific description of the size and location)
**Please be as specific as possible!!!!!
Dental Procedure - Please note all dental procedures include: general anesthesia, all teeth cleaned and polished, full-mouth dental x-rays, IV catheter and IV fluids. Extractions are not included in the standard dental price, and will be an added cost to the pet owner, if the Veterinarian deems them necessary during the procedure.
Spay (terminate pregnancy)Stop the procedure
Do You Authorize a Pre-Operative Blood Screen? We strongly recommend doing a routine blood screen prior to your pet receiving anesthesia today. The administration of anesthesia can sometimes affect organ function, especially the liver/kidneys. This important blood screen helps us determine if there are any additional precautions we may need to take prior to your pet’s procedure. *This pre-operative blood screen will add an additional fee.

Yes, I authorize this blood screenNo, I decline the recommended test
Please indicate if/which vaccinations/tests, or services, you would like us to perform today:

Please Note: WV state law requires a current Rabies vaccination on all pets. If your pet is NOT current on it's Rabies vaccine, one will be administered today, for an additional fee.
Rabies VaccineDHPP VaccineLyme VaccineBordetella VaccineCanine Influenza VaccineLeptospirosis VaccineHeartworm/Lyme/Ehr/ Ana Snap Test
Rabies Vaccine4in1/FVRCP vaccineLeukemia vaccineLeukemia/FIV/Heartworm Test
Anal sac expressionMicrochipOther
(CPR) I DO authorize HVH to perform life saving treatments on my pet. This may include the administration of medication, chest compressions, oxygen, ventilation, and other emergency measures deemed medically appropriate. I understand that in this event I will be contacted when the veterinarian is able to step away from the pet. I assume financial responsibility for all life saving treatments.(DNR) I DO NOT authorize HVH to perform life saving treatments on my pet. I authorize the attending veterinarian to minimize pain and sufferingafter the attempt to contact me. If the veterinarian is unable to contact me, I authorize the attending veterinarian to make the medically appropriatedecision that may include euthansia
Best phone number to reach you at today?
(XXX) -XXX- XXXX
YesNo
Owner/Agent Name (print):
Signature:
Today's Date:

MonthDayYear
Date
Any meds your pet is on?
(OTC or Prescription)
Last dose:
(Date and Time) (am or pm)
Should be Empty:

HILLSIDE VETERINARY HOSPITAL

Surgery Consent Form