Spay and Neuter Consent- Feline

Spay and Neuter Consent- Canine

Please fill out this form in entirety to ensure we can provide your pet with the best possible care.
Your Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Address*

Street Address

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Postal / Zip Code
Email
example@example.com
Pet's Name*
Possible Surgical Complications
General Surgery and Dentistry

- Anesthetic complications that could result in death
- Hemorrhage
- Dehiscence (breakdown of incision)
- Infections
- Necrosis (death) of skin
- Reaction to suture
- Delayed wound healing
- Fracture of jaw
- Oronasal Fistula
- Retained roots

Spay procedures (in addition to those listed under General Surgery)

- Hernias
- Bleeding during or after surgery internally, from the incision or from the vulva that can result in death
- Ovarian Remnant
- Urinary incontinence (occurs later in life)
- Urethral Trauma

Castration Procedure (in addition to those listed under General Surgery)

- Scrotal swelling or hematoma

- Hernias

These complications, although rare, are inherent risks of performing general anesthesia and surgery. This is not an all-inclusive list, and other complications are possible. Reading and following discharge instructions is the owner’s responsibility and is critical to healing and full recovery.

The treatment of these complications will be at the expense of the owner.
Pet History
Is your pet up to date on their vaccinations?*

YesNo, Being that we are a full-service clinic, we regularly treat animals with contagious diseases. We recommend your pet be fully vaccinated.
Please check the appropriate box if you would like us to update their vaccinations today:

Rabies $31.00DH(L)PP (Distemper/Parvo) $47.50Kennel Cough (Bordetella) $44.50
Is your pet allergic to any drugs?*

YesNo
Has your pet had any illness or injury in the past 30 days?*

YesNo
Any history of seizures and/or previous anesthetic problems?*

YesNo
Please provide details if you answered yes to any of the above history questions
Current Medications (including Supplements)? If yes, please indicate time of last dose.
SPAYING WHILE PREGNANT – OR- NEUTER with CRYPTORCHIDISM: Cost = $93.00
It is more difficult to spay a female dog that is in heat, pregnant OR neuter a cryptorchid male dog; therefore, there may be an additional charge. Sometimes we do not know your dog is in heat until we complete the pre-surgical examination. Other times, we find out your pet is in heat, pregnant or has fat surrounding uterus while in surgery.

If this occurs, we have the right to charge the additional price at the doctor’s discretion.
Authorization to complete procedure if pregnancy/cryptorchidism is detected during pre-surgical exam?*

YesNo
OPTIONAL SERVICES WITH SURGERY (ALL COSTS ARE ADDITIONAL)
There are many optional preventive health care services that can be provided for your pet during its surgery visit. We suggest the following procedures be done at the same time we are performing other necessary services for your pet. By allowing us to perform these elective procedures now, you will be providing optimum health care for your pet, while at the same time possibly saving you future additional expenses and heartache.
PRESURGICAL LABORATORY SCREENING: Cost = $72.50
This blood analysis provides us with information on the health status of your pet before surgery. Among other things, a preanesthetic panel analyzes liver and kidney health. This testing allows us to better tailor our anesthesia protocol to their individual needs. This service is highly recommended for any pet over 5 years old.*

Yes, please check my pets blood prior to anesthesia.No, I would like to decline blood work at this time.
INTRAVENOUS CATHETER AND FLUIDS: Cost = $104.00
While your pet is under anesthesia, we do our best to safeguard your pet’s health. Your pet can be further protected by the administration of intravenous fluids to maintain your pet’s blood pressure during surgery, counteract any blood loss, and speed their recovery from anesthesia. If an emergency were to arise, an intravenous catheter will help us greatly in our efforts to save your pet. This service is highly recommended for any pet over five (5) years of age.*

Yes, I would like intravenous fluids for my pet. $104.00No, I am declining intravenous fluids for my pet at this time.
DEWCLAW REMOVAL: Cost = Please ask staff member for estimate.
These claws are usually present on most pets at birth. When they are present, they tend to catch on objects, often causing the pet pain‑‑and sometimes bleeding if torn. Removal is easily accomplished at the time of spaying or neutering. This procedure does REQUIRE the use of an E-Collar for 10 days (no exceptions).*

Yes, I would like my pet's dewclaws removedNo, I am declining dewclaw removal
You elected to have your pet's dewclaws removed. Please specify*

FrontsBacksBOTH
RETAINED PUPPY TEETH REMOVAL: Cost = $19.20 per tooth
Occasionally, dogs will not loose all of their puppy teeth. Retained baby teeth can lead to gum infections and increased tartar buildup. It is best to remove these teeth when a dog is under anesthesia while being spayed or neutered.*

Yes, I would like my pet checked for baby teeth, and all baby teeth extractedNo, I am declining any extractions
EAR CLEANING & TREATMENT: starts at $36.00; Treatment = Varies
If we find that your pet has ear mites or an ear infection, we can easily clean and treat your pet’s ears while it is under anesthesia, which is easier on the pet than if they are awake.Medications to treat your dog’s ears will be an additional charge depending upon the condition.*

Yes, please check my pet's ear and treat as neededNo, I am declining any ear treatments
MICROCHIP IDENTIFICATION Cost: $68.50
This microchip will assign your pet a unique 10-digit code that can be used to identify or prove ownership of your pet. If your pet were ever to become lost, a microchip would help speed its return to your family. This is not a tracking device.*

Yes, please place a microchip in my petNo, I am declining a microchip placement
DEWORMING: Cost up to $22-60 (based on weight)
Recommended for pets over 4 months of age. Treatment for internal parasites including tapeworms*

Yes, please deworm my pet for internal parasites including tapewormsNo, I am declining deworming of my pet
Post-op Suit
E- collars are included with the procedure. Would you like to upgrade to a Post-op suit? (up to $41 based on size)*

Yes, please upgrade to a post op suitNo, I will stick with the E-Collar
RESUSCITATION CONSENT AT NO ADDITIONAL FEE

While all efforts will be made to assure the health and safety of your pet while under anesthesia,there are inherent risks with any anesthetic and surgical procedure. Occasionally, complications may arise during which we may need to resuscitate your pet. In order to better fulfill your wishes, we ask that you take a moment to consider the extents to which you wish us to go in order to save your pet.
Resuscitation Consent

Code 1: Do Not Resuscitate (DNR)**Code 2: External CPR (cardio-pulmonary resuscitation) Only
**IF CODE 1(DNR) IS SELECTED, PLEASE BE AWARE THE DOCTOR WILL NOT PERFORM ANY FORM OF CPR IF ANY COMPLICATIONS ARISE DURING THE SURGICAL PROCEDURE
I acknowledge my choice regarding resuscitation choice for my pet as noted above.
Initial
Surgery Release/Consent

By signing below, I acknowledge that I have read the POSSIBLE SURGICAL COMPLICATIONS form, and agree to release Sagehills Veterinary Services and their doctors and staff from any and all liabilities and legal claims that may occur as a result of surgery and/or complications that may develop. Any disputes shall be settled by mediation in Adams County, Washington.
Date

MonthDayYear
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Phone number we can reach you at while your pet is in our clinic?
Any pet that has fleas when admitted to the hospital will be treated for fleas at the owner’s expense
Should be Empty:

Spay and Neuter Consent- Canine

Possible Surgical Complications

Pet History

SPAYING WHILE PREGNANT – OR- NEUTER with CRYPTORCHIDISM: Cost = $93.00

OPTIONAL SERVICES WITH SURGERY (ALL COSTS ARE ADDITIONAL)

PRESURGICAL LABORATORY SCREENING: Cost = $72.50

INTRAVENOUS CATHETER AND FLUIDS: Cost = $104.00

DEWCLAW REMOVAL: Cost = Please ask staff member for estimate.

RETAINED PUPPY TEETH REMOVAL: Cost = $19.20 per tooth

EAR CLEANING & TREATMENT: starts at $36.00; Treatment = Varies

MICROCHIP IDENTIFICATION Cost: $68.50

DEWORMING: Cost up to $22-60 (based on weight)

Post-op Suit

RESUSCITATION CONSENT AT NO ADDITIONAL FEE

Surgery Release/Consent