Yucca Veterinary Medical Center | Surgery Consent Form

Yucca Veterinary Medical Center | Surgery Consent Form
Client (Full Name)*

First NameLast Name
Today's Date*

MonthDayYear
Date
Pet's Name*
Pet's Age*
My pet is here for the following procedure today:*
Date the procedure is schedule for:*

MonthDayYear
Date
Phone number where you can be reached today:*
Please enter a valid phone number.
Is there anything in addition to the procedure you would like the doctor to examine today or any concerns regarding your pet?*
Has your pet ever had an adverse reaction to any type of medication, vaccine or sedation?*
Has your pet shown any signs of illness such as vomiting, diarrhea, coughing, sneezing?*
Would you like us to call or text when your pet is awake from the procedure?*
Pre-Anesthetic Blood Testing
Many conditions may not be detected unless bloodwork is performed. Before putting your pet under anesthesia, we recommend running a full blood panel to make sure that all the internal organs are functioning correctly before putting your pet under anesthesia. A blood panel and Complete Blood Count will tell the doctor currently how your pet's body is functioning and can serve as a baseline for future visits. The cost to run the bloodwork is $125.00.

It is important to understand that pre-anesthetic bloodwork does not guarantee the absence of anesthetic complications. It may however, greatly reduce the risk of complications in identifying medical conditions that could require medical treatment today or in the future.
Would you like us to run pre-anesthetic bloodwork?*

YES, I would like to run the pre-anesthetic bloodwork.NO, I understand the consequences of not running blood testing and decline the service at this time.
We RECOMMEND every pet that has Surgery goes home with an E-Collar. Would like us to automatically send one home with your pet after surgery today? (If you decline and your pet begins to lick or chew while in our office, there will automatically be an extra charge for an e-collar.)*

YESNO
NAIL TRIM FOR $7.00*

YESNO
Ear Cleaning or Ear Flush for $28.00*

YESNO
Microchip Implant: While under anesthesia, would you like for your pet to be implanted with a Homeagain microchip as a means of permanent identification?*

YES, I would like my pet microchipped for $26.00 for a lifetime registration.NO, I am not interested in microchipping at this time.
Vaccination Authorization
I would like the following vaccines administered to my pet. I understand that my pet is required to be current on the Rabies vaccination according to New Mexico Health & Disease Control. If I cannot provide record of a current Rabies vaccination, my pet will receive a one year Rabies vaccine today for a charge of $16.00.*

My pet is up-to-date on a rabies vaccine.I decline all vaccinations for my pet today.
Please provide clinic name that administered your pet's vaccine, if not with us:*
Please vaccinate my pet for the following vaccines:

Rabies 1 yearRabies 3 yearDistemper/ParvoCanine influenzaBordetella (kennel cough)RattlesnakeFeline RespiratoryFeline Leukemia
Parasite and Heartworm Prevention
We recommend your dog being on a monthly heartworm prevention. Mosquitos, fleas and parasites from the environment and cause disease in your pet. To prevent your pet from becoming infected, we recommend a monthly product as well as year deworming.
Would you like to have your dog tested for Heartworm or Heartworm & Tick disease today? The test is $37.00 for flea and tick test, or $20.00 for the heartworm only test.*

YESNO4DXHEARTWORM ONLY
Would you like to take Heartworm Prevention home?*

YESNO
Would you like the Heartworm Injection completed?*

YESNO6M INJ.12M INJ.
Would you like your dog or cat dewormed?*

YESNO
Would you like flea/tick product for your dog or cat today?*

YESNO
Laser Therapy
Not used on mass/growth removal procedures or cancer patients.

Post-operative laser therapy will improve post-operative pain relief and provide a faster incision healing. Light energy enters the cells to stimulate intracellular activity to provide healing benefits. It is an additional $22.00 cost for the treatment.
Would you like us to do a laser therapy session on your pet today?*

YESNO
For Spay (Ovariohysterectomy) Procedures Only - If your pet is found pregnant:

YES, I would like the veterinarian to continue with the spay procedure. (There will be an additional $45.00 charge added to the invoice, and I understand that if my pet is pregnant, the pregnancy will be terminated during surgery.)NO, I would NOT like the veterinarian to continue with the spay procedure.
Are you leaving any belongings with your pet today? (The clinic will not be responsible for any lost items.)*
As the owner or owners agent with permission from the owner of the above pet, I certify that I am over the age of 18 and I authorize the staff of this hospital, Yucca Veterinary Medical Center, to perform the procedure(s) listed above, as well as those deemed necessary to treat life-threatening emergencies. As with all anesthetic, treatment, and/or surgical procedures, I understand there are risks inherent in these services. I understand there are risks with any patient going under and recovering from anesthesia. I understand that these risks range from injury to death. I understand that Yucca Veterinary Medical Center can refuse service to animal that appears to be a health and/or safety risk. I understand that some health factors increase surgical risk including but not limited to: pregnancy, disease such as heartworm, FIV, Feline Leukemia, etc. I understand that by bringing my animal to an environment where other animals are present, there is risk for contagious disease. I will not hold Yucca Veterinary Medical Center liable for any illnesses that my pet currently has or may develop in the future. I acknowledge that staff members at this practice have explained the procedures to me, answered questions to my satisfaction and cannot be held responsible for any unforseeable results. Further, I understand that I am financially responsible for all costs incurred during this surgery, treatment and hospitalization. I understand that payment in full is due at the time my pet is released from the hospital.

I understand no staff will be attending to my pet overnight. (We can always refer your pet to a 24 hour facility at your expense if you would like.)
Client Signature

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Today's Date

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Yucca Veterinary Medical Center | Surgery Consent Form

Pre-Anesthetic Blood Testing

Vaccination Authorization

Parasite and Heartworm Prevention

Laser Therapy