Surgery Consent E-Form

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Surgical/Anesthesia Consent Form
Client Information & Patient Information
Owner's Name*
First and Last
Email Address
example@example.com
Pet's Name*
Sex*
Species*
Breed*
Ex: Pug, Dachshund or Domestic Shorthair
DOB or approximate age*
Please include days, months or years if giving approx. age (ex: 7 days, 10 weeks or 5 years)
Scheduled Procedure(s)*
I am the owner of the animal named above or I am responsible for him/her and have the authority to give consent for the above procedure(s).
Date of Procedure*

MonthDayYear
Date
Please acknowledge that you will take up your pet’s food and water at 10pm the night before the procedure*
Consent to Spay

Females only
Has your pet been in heat recently?
Could your pet be pregnant?
If your pet may be pregnant and you do not wish to terminate her pregnancy, please speak with the veterinarian about further testing.

If your pet is found to be pregnant during the spay surgery, you understand that this procedure will terminate the pregnancy.
By initialing below you understand your consent to spay

Clear
Vaccination Policy
Surgery patients must be current on vaccinations. If not, vaccinations will be given at the time of surgery at an additional cost to the owner.

Rabies $27, DHPL-Parvo $73, Bordetella $33, FVRCP $40
By initialing below you agree to the vaccination policy*

Clear
I understand that canines must be current on Rabies, DHPL-Parvo and Bordetella. Felines must be current on Rabies and FVRCP.
Preoperative Bloodwork Policy
Preoperative bloodwork is mandatory for all patients 8 years of age or older undergoing general anesthesia. This bloodwork allows our veterinarians to assess the patient’s overall health, ensuring that your pet is a good candidate for anesthesia and decreasing certain risks and complications.
By initialing below you agree to the bloodwork policy and accept the additional charge of $172

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Pain Management Policy
Midwest Veterinary Hospital requires post-operative pain medications at an additional charge for all pets after surgical procedures (excluding teeth cleanings without extractions). Pain management is important to your pet's overall healing process; an injection will be given immediately prior to surgery and your pet will be sent home with pain medication for at least 4 days following surgery. Animals may not appear to be in pain after surgery, but they are. Alleviating pain will allow your pet to be more comfortable and heal faster.

Charges for post-op pain medication vary by weight and should have been included in your quote upon scheduling.

Dogs 1-40lbs $43

41-80lbs $55

81-120lbs $68

>121lbs $86

Cats $36

If you have any questions or concerns, please feel free to contact us at 405.732.4505 or email us at reception.mwvh@gmail.com.
By initialing below you agree to the pain management policy and accept the additional charge listed above that will be determined by your pet's weight at the time of the pre-op examination*

Clear
Flea and Tick Policy
If fleas and/or ticks are found on your pet while in our care we will administer flea and tick treatment at an additional cost to the owner.
Is your pet on flea/tick prevention?*
If yes, what brand of flea/tick prevention and when was the last dose:*
By initialing below you agree to the flea and tick policy*

Clear
Please use the file upload to include your pet's vaccination record and/or significant medical history

If you are unable to upload records, please email them to reception.mwvh@gmail.com or bring the records with you to your upcoming appointment.
File Upload

Please attach vaccination record and/or significant medical history
Cancelof
Additional Services

To be performed during anesthesia/sedation if time and/or schedule permits
Clean teeth

$96 (extractions and anesthesia is an additional charge)
Post-op pain injection

$60-$70 (depends on size and weight)Post-op pain injection - ONLY IF NEEDED (to be determined by the surgeon)
HomeAgain microchip implantation for ID purposes

$77 (includes yearly fee of $19.99)
Removal of warts

Surgically or electrocautery (ask surgeon for quote)
Express anal glands

$33
Flush ears

$46-$68
Nail trim

$24.50
I authorize the use of any anesthesia necessary for the previously stated surgical, diagnostic, or therapeutic procedures. I understand that certain risks and complications may be involved in the surgical procedures/anesthesia. Midwest Veterinary Hospital uses advanced anesthetics that are relatively safe and have low rates of complications. However, problems can arise because of pre-existing conditions not evident during pre-anesthetic exams.
To decrease these complications, we advise a blood profile to be performed prior to anesthesia. On all dogs, we also recommend a yearly heartworm test and heartworm prevention.

I authorize a pre-anesthetic blood profile to be performed at an additional cost of $172 (includes a blood collection fee of $19.75)I authorize a heartworm test to be performed at an additional cost of $61.75 (dogs only, includes a blood collection fee of $19.75)
Signature*

Clear
Date*

MonthDayYear
Phone number where you can be reached today*
Please enter a valid phone number.
Any additional comments or concerns that you would like addressed during the pre-operative exam?
Questions for the veterinarian
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Should be Empty:

Client Information & Patient Information

Consent to Spay

Vaccination Policy

Preoperative Bloodwork Policy

Pain Management Policy

Flea and Tick Policy

Please use the file upload to include your pet's vaccination record and/or significant medical history

Additional Services