Surgery Consent Form

1
Owner/Responsible Person* This field is required.
2
Are you the person responsible for decisions and accounts?* This field is required.This person should be the owner on account, responsible for decisions and payments and of legal age
Yes
No
3
Email* This field is required.
example@example.com
4
Phone Number * This field is required.Please list a number that you can be reached at during and after surgery, It is important that you be available to answer while we have your pet in the clinic.
Please enter a valid phone number
5
Secondary Contact NameThis person needs to be authorized to make medical and financial decisions in case we can not reach you.
First Name
Last Name
6
Secondary Contact Number
Please enter a valid phone number
7
May we text you?* This field is required.
Yes
No
8
Patient's Name * This field is required.
9
Date of patient surgery appointment* This field is required.
Date
Year
Month
Day
10
Species (Dog or Cat)
11
Age/Date of Birth
12
Breed
13
Sex
Male
Male (neutered)
Female
Female (spayed)
14
What procedure is your pet scheduled for?* This field is required.
Please Select
Please Select
Spay (Female)
Neuter (Male)
Mass Removal
Dental
CCL (Knee Surgery)
Cystotomy (Bladder Stone Removal)
Laceration repair
15
When did your pet have food or water last?* This field is required.
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
10
20
30
40
50
Minutes
AM
AM
PM
16
Has there any change in your pets medical condition since we last saw them?* This field is required.
Yes
No
17
Is your pet on any Medications/Supplements/CBD oil? If yes, please list the names, dose, strength of each and WHEN THE LAST DOSE WAS GIVEN.* This field is required.If none, type "None"
18
Is your pet aggressive where we need to take extra precaution?* This field is required.
Yes
No
19
Additional Services Desired While Patient is SedatedAdditional cost will apply
Implant Microchip
Clean Ears
Nail Trim
Nail Dremel
Express Anal Glands
Sanitary Clip (rectum, genitals)
20
Lab work results can take up to 48 hours to receive. Histopath or Cultures can take up to 14 days to receive. How would you like to be contacted once we receive your pet's results?
TEXT
PHONE CALL
21
Therapeutic Laser Treatment* This field is required.
I would like for my pet to receive Therapeutic Laser Treatment to assist healing following the procedure
I would NOT like for my pet to receive Therapeutic Laser Treatment to assist healing following the procedure
22
In the event of an emergency* This field is required.
I do authorize CPR or other life saving procedures in the event of any emergency
I do NOT authorize CPR or other life saving procedures in the event of an emergency
23
Cancellation/Reschedule Policy

Your pet's surgery requires the coordination of authorization forms, the surgeon, the anesthesia nurse and blocking off time from our appointments. Rescheduling requires significate time and expense, particularly if the operating room goes unused due to cancellation. We required a deposit of $200.00 to schedule any surgery, 2 days prior to the surgery date. If you choose to reschedule your pet's surgery, you must do so 48 hours to the surgical appointment.
24
Surgery Consent

I authorize the use of appropriate anesthetic agents as are deemed necessary for the treatment of my pet. I further understand that there are certain risk involved with all types of anesthesia and procedures. I acknowledge that no guarantee has been made as to results that may be obtained. I assume financial responsibility of all charges incurred to this patient. I am also aware that payment in full is due at the time the animal is discharged.
25
Type full name as signature* This field is required.By signing your name you agree and acknowledge the surgery consent statement and cancellation/reschedule policy.
First Name
Last Name
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