CANINE STANDARD CONSENT FORM

Lahontan Valley Veterinary Clinic

3660 Schurz Highway Fallon, Nevada 89406 (775) 423-7528

Date

I am the owner or agent for the owner of the above described animal and have the authority to execute this consent. I hereby consent and authorize the performance of the following procedure(s) or operation(s):

Choose which procedure we are preforming today.

I understand that during the performance of the foregoing procedure(s) or operation(s), unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure(s) or operation(s) or different procedure(s) or operation(s) than those set forth above. Therefore I hereby consent to and authorize the performance of such procedure(s) or operation(s) as are necessary and desirable in the exercise of the veterinarian's professional judgment. I also authorize the use of appropriate anesthetics and other medications and I understand that hospital support personnel will be employed as deemed necessary by the veterinarian. I have also been informed that there are risks associated with the use of any medication. I have been advised as to the nature of the procedure(s) or operation(s) and risks involved. I realize results cannot be guaranteed. As part of our normal surgical procedure a catheter will be placed and IV fluids will be given during surgery.

PRE-ANESTHESTIC BLOOD TESTING

Before putting your pet under anesthesia, a physical exam will be performed. As part of the pre-surgical examination, we offer a pre-anesthetic blood panel. These tests are similar to those your physician would run if you were to undergo anesthesia. These tests may be useful in diagnosing liver/kidney disease, diabetes, or other conditions that could complicate a surgical procedure.

Pre-anesthetic blood work? ($101)

YESNO, I understand the potential risks involved.

Pain Management (Cost varies by weight)

Pain medication with surgery and sent home. (promotes healing)Pain medication with surgery only.No, I decline pain medication.

Heartworm Test

Yes, I would like my pet tested. ($49.75)No, I decline heartworm testing.

If negative, would you like Heartworm medication sent home (test results are good for one month without medication)?

YESNO

Would you like to have you pet microchipped with a 911 PetChip and Lifetime registration? ($41)

YESNO

DENTAL CLEANING/EXTRACTION

If your pet is scheduled for a dental cleaning, a licensed technician or veterinarian may perform the procedure. Extractions may be a necessary part of the dental procedure. If you mark yes for extraction a veterinarian will extract the necessary teeth. Diseased teeth can be a source for re-infection.

I consent to allow the veterinarian to extract all teeth necessary. (Cost varies with difficulty)

YESNO

If we are removing a growth would you like it sent in to the pathologist for identification? ($375.00 per site)

Yes, I would like the growth sent in for identification.No, Do not send in for identifications.

Owners Consent

I have read and understand this authorization and consent and am aware that payment for today's services is required before I collect my pet. I also understand that Lahontan Valley Veterinary Clinic is not staffed 24 hours a day and my pet will not have overnight medical supervision.

Owners Signature

Witness to the signature (Clinic Staff)

Good contact number

May we text you at this number with updates on your pet?

YESNO

Last Food and Water

Medications (antibiotics, prescriptions, etc.)

Last given

I will allow an intern to perform the above procedure/surgery under the direct guidance of veterinarians.

YES

Would you like us to fit your animal for an E-Collar to send home? An E-Collar is strongly suggested by our Veterinary staff. The collar helps aid in healing. The pet will want to lick the incision which can cause an infection or at the least slow the healing process. The cost is between $12 and $32.

YESNO. I understand the complications that may occur.

CANINE STANDARD CONSENT FORM

GROWTH REMOVAL (HISTOPATH)