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?
For Cats Only:

IndoorOutdoorIndoor/Outdoor
Breed:
Sex:
Color:
Birthdate/Age:
Telephone:
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.
Female pets : Please note there is an additional fee if your pet is pregnant or in heat. If your pet is found to be pregnant or in heat, how do you want us to proceed? PLEASE CHOOSE ONE OPTION FOR ALL FEMALE ANIMALS.

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.
DOG Services:

Rabies VaccineDHPP VaccineLyme VaccineBordatella VaccineCanine Influenza VaccineLeptospirosis VaccineHeartworm/Lyme/Ehr/ Ana Snap Test
CAT Services:

Rabies Vaccine4in1/FVRCP vaccineLeukemia vaccineLeukemia/FIV/Heartworm Test
Additional Services:

Anal sac expressionNail TrimMicrochip
AUTHORIZATION: I verify I am the owner (or authorized agent for the owner) of the above-named pet and authorize the above procedure to be performed. 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(s) as directed by the veterinarian. I have been advised as to the nature of this procedure to be performed and the risks involved. I understand also that there is always a risk associated with any anesthesia episode, even in apparently healthy animals and have discussed my concerns with the veterinarian. 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 judgement. I accept responsibility for any result in additional charges. I agree to be responsible for any 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. I understand no staff will be attending to my pet if it stays overnight (pets needing special care may be referred to a 24 hour hospital)
Best phone number to reach you at today?
(XXX)-XXX-XXXX
May we text?

YesNo
Owner/agent Name (print):
Signature:

Clear
Date

MonthDayYear
Date
Any meds your pet is on?
Last dose:
Should be Empty:

HILLSIDE VETERINARY HOSPITAL

Surgery Consent Form