Surgical Consent Form

Client Name

First NameLast Name

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Patient Name

Species

Breed

Age

Sex

Color

Last Time Food Was Given

Date

Hour MinutesAM/PM Option

Is Your Pet Showing Any Signs of Illness?

If Yes, Please Explain the Signs of Illness

Is Your Pet On Any Medication?

If Yes, Please List All Medications and Instructions

Has Your Pet Had Any Past Surgeries?

If Yes, Please Describe Any Past Surgeries

Has Your Pet Had Any Previous Reactions to Anesthesia?

For male pets: are both testicles descended?

Is Your Pet Pregnant?

Does Your Pet Currently Have Fleas?

Note: Pets overdue for vaccines must be made current during hospitalization at the owner’s expense. Pets with fleas will receive flea treatment at the owner’s expense.

Authorization Acknowledgment

I, the undersigned, do verify I am the owner (or authorized agent for the owner) of the above named pet and authorize the above procedure to be performed. 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(s) as directed by the veterinarian.

I, the undersigned, have been advised as to the nature of this procedure to be performed and the risks involved. I understand also that there is always a risk associated with any anesthesia episode. Although rare, even in apparently healthy animals, serious complications, even death, may occur. I have discussed any concerns with the veterinarian. I understand that it may be necessary to provide medical and/or surgical procedures, which are not anticipated for the safety and care of my pet. I, the undersigned, do 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 anything that results in additional charges.

I, the undersigned, agree to be responsible for any 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.)

Payment

Payment for today is due in full at the time of pick-up. We do not accept checks, nor do we do have payment plans. Cash and all major credit cards (except for American Express) are accepted.

At approximately 6 months of age, most cats and dogs typically have lost all baby teeth, which have been replaced by adult teeth. In some cases, especially in small or toy breed dogs, the adult tooth has erupted but the baby tooth is still present. The average amount of retained teeth observed in dogs with this issue is 1-2 teeth. These retained teeth can cause significant dental problems down the road. It is recommended at the time of spay or neuter to have these baby teeth removed, as the pet is already under anesthesia. If upon exam we find your pet has retained teeth, would you like us to remove them? The additional cost will be $75 per tooth. If retained baby teeth are found upon exam, would you like them removed?

Signature

Date

Surgical Consent Form

Owner / Client Information

Patient Information and Pre-Op Screening

Authorization, Baby Teeth, Payment, and Signature