Fayetteville Animal Clinic Surgery Consent Form
*Pet(s) must be current on vaccinations or they will be given at the owner's expense.
Please provide paperwork, or proof of vaccination, if your pet has been vaccinated elsewhere when you drop them off!
Surgical Procedure
I consent to the following vaccinations to be given:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Vaccinations
Rabies
DHLP Parvo
Bordetella
FVR CP
Feline Leukemia
I have not given my pet any food or water after midnight on the night before the procedure.
Yes
No
Client Name
Pet(s) Name
Date
-
Month
-
Day
Year
Date
Client Daytime Contact Number(s)
-
Area Code
Phone Number
Emergency Contact Person
Emergency Phone
-
Area Code
Phone Number
PRE-ANESTHETIC BLOODWORK RECOMMENDATIONS
(additional charges will be applied-please mark yes or no)Our greatest concern is the well-being of your pet. We will perform a physical examination before administering anesthesia. However, disorders of the liver, kidneys, or blood, are not detected unless blood testing is done. Abnormalities of any of these may increase anesthetic risk. For these reasons we highly recommend pre-anesthetic blood screens, especially for geriatric patients greater than 7 years old.
Canine Heartworm Test
Yes
No
Feline Leukemia and FIV Test
Yes
No
Complete Blood Count and 10 Chemistry Panel
Yes
No
ADDITIONAL OPTIONAL SERVICES (additional charges will be applied)
Nail Trim
Fecal
Express Anal Glands
HomeAgain Microchip Identification
Cold Laser Therapy reduces post-operative pain and swelling at the incision and can speed recovery $10.00 - $12.00
AUTHORIZATION TO PERFORM SURGERYI here by authorize FAC to perform such diagnostic and surgical procedures as described above. I understand that there are rare complications associated with any anesthetic or surgical procedure. No warranty or guarantee has been given to me as to the results or cure afforded by these treatments or procedures. I understand that I assume financial responsibility for all services rendered and agree to pay all charges (including boarding costs) upon release of pet from the clinic.
I do not want my cat or dog spayed if she is pregnant.
I have read and fully understand this surgery and anesthesia consent form.
*If in the event of an emergency situation, I authorize FAC to do whatever you deen necessary to treat my pet.
Yes
No
Submit
Should be Empty: