Fayetteville Animal Clinic Surgery Consent Form

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
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.
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
Should be Empty:

Fayetteville Animal Clinic Surgery Consent Form

*Pet(s) must be current on vaccinations or they will be given at the owner's expense.

I consent to the following vaccinations to be given:

PRE-ANESTHETIC BLOODWORK RECOMMENDATIONS