Canine Spay Consent Form

Client Name*

Patient Name*

Patient Age*

Breed*

Sex*

Date of procedure*

Date

Preferred Contact Number(s)*

Preferred Contact Method*

Phone CallText

Is your pet currently on any medication?*

YesNo

If yes, please list medication and how often administered

Base Spay* Price

0-24lbs	$562.25
25-49lbs	$609.25
50-74lbs	$656.25
75-99lbs	$735.25
>100lbs	$781.25

Our base spay and neuter fees include the following:

Pre anesthetic surgical assessment (current wellness exam is required for all surgical procedures)
Pre anesthetic ECG screening
IV Fluids
Gas anesthesia using isoflurane with respiratory, oxygen and heart rate monitoring
Surgical procedure
An injection of a long acting 72 hour narcotic pain medication and 24-hour anti-inflammatory at time of surgery
A 24 hour injection of an antiemetic medication to prevent postoperative nausea and discomfort
Anti-inflammatory pain medication to go home post operatively
Nail trim

A current wellness exam performed here is required for all surgical procedures. If this is due at the time of the procedure the cost is an additional $80.00

OPTIONAL:

The following are optional (except for patients 7 years and older) but recommended add ons to your pet's procedure. By choosing yes next to the option, you are asking that we perform that service. Please read each one carefully and let us know if you have any questions.

PRE-ANESTHETIC BLOOD SCREEN:

A physical exam will be performed on your pet prior to the surgical procedure. However, this may not identify all systemic or metabolic problems. For this reason, we highly recommend a pre anesthetic screen for all patients.

Pre Anesthetic Blood Screen (for patients under 7yrs) I $197.00*

YesNo

It is required for pets 7 years of age and older at a higher fee due to a more comprehensive test needed. I acknowledge that if my pet is 7 or older this will be performed.*

Yes

Laser Upgrade:

The CO2 laser seals as it cuts resulting in very little to no bleeding at the incision site. Since the nerve endings are also sealed they transmit less of the pain sensation. The healing time is the same whether using laser or scalpel.

Laser Upgrade | $39.50*

YesNo

Microchip:

If your pet does not already have one, we can implant at the time of surgery. Microchips are strongly recommended for ALL pets to ensure their best chance of being returned should they ever get lost. Our chips come with a lifelong registration.

Microchip | $52.00

Yes

Sedatives I $21.50-$30.00*

I would like pre and post surgical sedatives*I would like post surgical sedatives onlyI would like pre-visit sedatives only*I decline any sedatives

Sedatives can assist keeping your pet quiet during it's 2 week recovery period. Please refer to our surgery information page and let us know if you would also like *pre-visit sedatives dispensed for pick up prior to the day of surgery.

It is important that your pet does not lick or chew at his/her incision until completely healed. To assist with this we offer the follow options:

Elizabethan Collar (cone) I $12.75-$22.75Soft Inflatable Round Collar I $11.00-29.00Post Surgical Recovery Bodysuit* I $27.00-$42.00

*Bodysuits are gender specific so no need to remove for bathroom breaks

Extraction of Baby Teeth
Most dogs should have lost all of their baby teeth by the time they are 6 months of age. If these teeth do not fall out on their own by this time, we strongly recommend extracting the teeth while they are under anesthesia for their spay or neuter. Leaving retained deciduous teeth can cause crowding to adult teeth and collect debris and build tartar that cause more dental issues long term. While any breed can retain baby teeth, it is most commonly seen in smaller breeds.

Extraction of Baby Teeth | $36.75 - $47.75*

YesNo

By declining any post-surgical protection, I acknowledge that I will be responsible for any fees incurred for medication or services due to my pet licking or chewing at the incision.

Yes

Please note that if your pet is pregnant, in heat, pre or post heat, or does not have both testicles descended at the time of the surgery, additional fees will apply.*

Yes

If your pet does not have a current general exam with us this will need to be done at the time of surgery. If you would like to be present for the physical exam to address any concerns directly with the doctor, please make a separate pre surgical appointment. Otherwise, this will be performed just prior to anesthesia.*

Yes

Please read the following and sign below:

I understand that some risks always exist with anesthesia and surgery and that I am encouraged to discuss any concerns I have with the attending veterinarian about those risks prior to the procedure.

I understand that the attending veterinarian will make every effort to contact me regarding treatment in the case of unforeseen emergencies.

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved.

If my pet needs to be hospitalized after hours, I acknowledge they will be unattended for a period of time between shifts as we are not staffed overnight.

I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed such as radiographs, re-check examinations, and additional surgery due to post-op complications. These are more likely to occur when there is failure to comply with the aftercare instructions that will be provided the day of surgery.

PAYMENTS FOR SERVICES PROVIDED FOR YOU AND YOUR PET IS EXPECTED AT THE TIME SERVICES ARE RENDERED. Acceptable forms of payment include cash, American Express, debit, Discover, Visa, or MasterCard. We do not accept payment plans. For larger invoices, you have the option of applying for financing through Care Credit. It is a third-party form of financing that does not have finance charges so long as you pay off the balance within 6 months. Insured Pets: You are still responsible for payment on your account at the time of service. Insurance reimbursement is between the insurance company and the insured. Overdue accounts will be turned over to a collection agency.

I have read and fully understand the terms and conditions set forth above.

Signature*

Date*

Please remember to not feed your pet 8 hours prior to drop off for surgery

*biohazard medical waste fee will be added to all surgical procedures.

Canine Spay Consent Form

Post Surgical Collars or Bodysuits: