Surgery Consent Form

Pet's Name*

First NameLast Name

Who is your pet seeing today?

Your Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

It is imperitive that we be able to reach you in a timely manner while your pet is in the building today. Please give us the phone number that you will answer while your pet is visiting GVH today.

Where can we call you at while your pet is here?*

Area CodePhone Number

Is there anyone else we can call regarding your pet while they are here today?

YesNo

Alternative Contact Name*

First NameLast Name

Alternative Contact Phone*

Area CodePhone Number

Reason for your pets visit today?

Please list type of surgery. For example: lump removal, cystotomy, etc.

Has your pet had any food since midnight last night?

YesNoUnsure

Has your pet been vomiting or having diarrhea?

YesNoUnsure

Does your pet have any allergies?

YesNoUnsure

If yes, please describe/provide more information

Has your pet ever had any adverse reaction to medication?

YesNoUnsure

If yes, please describe/provide more information

Please list any medications, supplements, topical treatments your pet has received in the past 72 hours and when they were last given:

When Was Your Pet's Last Dose of Flea/Tick Preventative?

Date Given (Please type N/A if not on a preventative)

What Kind of Flea/Tick Preventative Do You Use?

Name of medication - put unknown if not sure

Is Your Pet Current On Vaccinations?

YesNoI Am Not Sure

My pet's vaccines were administered last by:

Glastonbury Veterinary HospitalI Am Not Sure WhereOther

I authorize the use of appropriate anesthetics and other medications. I understand that anesthesia does present a risk to my pet's life, and I accept that risk as a part of the procedure(s). To help reduce the risks involved with anesthesia, Glastonbury Veterinary Hospital recommends a pre-surgical blood screen to evaluate your pet's internal status if the pet is less than 5 years. It is required for pets over 5 years of age. This test checks kidney and liver function (these systems metabolize the anesthesia), a complete blood count (this would alert us to any infection, clotting problems, or anemia), and blood glucose level (blood sugar). (Additional Fees Apply)*

Yes, I authorize GVH to perform pre-anesthetic labwork.No, I would like to decline blood work at this time.

*Only applicable if your pet is getting a lump or tumor removed. We recommend histopathology on all lumps or tumors removed in order to identify the type of tumor and level of aggressiveness. These results typically take about 5 - 7 days to get back. (Additional Fees Apply)

Yes, I would like the mass sent off for histopathology.No, I do not authorize histopathology

Would you like a microchip implanted today? Keep in mind if you plan to travel outside of the USA with you pet, it is a requirement to have a microchip prior to any rabies vaccine.

Is There Anything Else We Should Know About Your Pet?

If yes, please tell us more. If no, please note N/A

I verify that I am the owner (or authorized agent for the owner) of the above named pet and authorize treatment of my pet to be performed by Glastonbury Veterinary Hospital. 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 as directed by the veterinarian.*

Initial

I have been advised as to the nature of this procedure to be performed and the risks involved. No guarantees have been made regarding the outcome or cure. I understand that there is always a risk associated with any sedation or anesthesia episode, even in apparently healthy animals, and have discussed my concerns with the veterinarian. The veterinarian has provided me the opportunity to ask questions and receive answers regarding the procedure. This risk includes serious bodily injury or death. 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 judgment. I accept responsibility for any result in additional charges.*

Initial

I agree to be responsible for all 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 overnight (pets needing special care may be referred to a 24 hour hospital).*

Initial

In the event of an unforeseen emergency, we will attempt to reach you without delay. Please know that we will take every precaution to ensure that your pet is safe and healthy enough to undergo their procedure today. Any known risks will be discussed with you. However, very rarely, emergencies do happen and we want to know your preference if no one can be reached. Please check your preference:*

Please proceed with basic cardiopulmonary resuscitation (CPR).Please do not proceed with basic cardiopulmonary resuscitation (CPR).

I acknowledge my choice regarding resuscitation choice for my pet as noted above.*

Initial

Signature*

Surgery Consent Form

Authorizations