Fourmile Veterinary Clinic - Surgery Consent Form

Surgery Consent Admission Form
Client's Name*

First NameLast Name
Phone Number*
Pet Information
Pet Name*
Pet's Age*
Pet's Weight*
Species*

DogCatEquineBovineOther
When was the last time your pet had food (list time and am/pm)?*
When was the last time your pet had water (list time and am/pm)?*
Does your pet have any major medical conditions (i.e. diabetes, seizures, kidney/heart disease, etc.)?*

YesNo
If yes, explain below:*
If your pet currently taking any medications?*

YesNo
If yes, list the medications and the last time given.*
Please note: Personnel trained in patient observation will not attend the patient continuously outside regular office hours. If you
prefer a facility with 24 hour staffing we would refer you to an emergency clinic in Pueblo or Colorado Springs.

As the owner or agent of the above animal. I hereby give my consent to Fourmile Veterinary Clinic to perform the
following procedures:

Pre-Anesthetic Lab Work
If your pet is to be anesthetized, rest assured that advances in anesthesia and surgery have made routine procedures relatively
safe, with a low rate of complications. Nevertheless, occasional problems can arise, due to pre-existing conditions not evident
during routine pre-anesthetic examinations. In-house pre-anesthetic blood tests are another tool to gain information that may
decrease the risk of anesthesia and surgery. They give us vital physiologic information as to your pet’s liver, kidneys, electrolyte
balance, and screens for diabetes, underlying infection and anemia that would go undetected with just a physical examination.
Therefore, the blood test is recommended for dogs & cats under 7 years old; and is required for dogs and cats 7 years &
older and for high-risk pets. However, there can be sensitivities to anesthetic agents that cannot be detected by either physical
examination or pre-anesthetic blood work. These are very uncommon, and every effort will be made to use the safest and best
anesthesia for your pet.
E-Collar*

Yes, I want an E-Collar ($7-15 based on size)No, I do not want an E-Collar
Blood Work*

Yes. I would like the Complete Pre-Surgical Profile ($92.00) test performed prior to anesthesia on my petI do not want the Complete Pre-Surgical Profile test performed prior to anesthesia. I understand that the above test is recommended for dogs and cats under 7 years; and is required for dogs and cats 7 years & older and high risk pets.
Client, please check the appropriate boxes:*

SpayNeuterMicrochipHeartworm TestVaccinationsDentistryOther
Spay, I give permission to spay my pet if pregnant*

YesNo
How many weeks pregnant? Write N/A if not pregnant*
Is your pet in heat?*

YesNo
What vaccinations does your pet need?*
Dentistry: EXTRACTIONS ARE NOT INCLUDED IN ROUTINE DENTAL CLEANING COST:*

Please extract the necessary teethNo extractions authorizedCall before extracting
Yes. 1 understand that during the performance of this procedure, unforeseen conditions may be revealed that necessitate
an extension or variance in the procedure(s) set forth above. Post procedure pain medication will be dispensed at the Doctor's
discretion. 1 authorize Fourmile Veterinary Clinic, using reasonable care and judgment, to perform any additional procedure(s)
that may be deemed necessary. I am aware that there are inherent risks involved with the above procedure(s) and that results
cannot be guaranteed. I am also aware that unforeseen events resulting from the procedure(s) will not relieve me from any
obligation for all reasonable costs incurred regarding this animal. Full payment is due at the time of the service.
Signature*

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Today's Date*

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Surgery Consent Admission Form

Pet Information