Surgery Consent Form

Your First Name:
Your Last Name:
Phone:
Email:
Your Pet's Name:
Age:
Sex:
Breed:
Color/Markings:
Procedure(s):
For mass removal(s), location(s) of mass(es) to be removed:
Most recent access to food:

I, the owner or responsible party, understand that if my pet has eaten within 6 hours prior to anesthesia, there is increased risk of vomiting, aspiration, or other complications, including death.

Known health conditions: NoneCoughingThyroid diseaseEstrus (heat)LethargySneezingHeart diseasePregnancyInappetenceVomitingKidney diseaseCancerDiarrheaLiver diseaseOther:

Current Medications:

Flea and Tick Preventative:

Product:
Dose:
Last Administered:

Heartworm Preventative

Product:
Dose:
Last Administered:

Meds #1

Product:
Dose:
Last Administered:

Meds #2

Product:
Dose:
Last Administered:

Meds #3

Product:
Dose:
Last Administered:

Supplements

Product:
Dose:
Last Administered:

Anesthetic Risk:

Your pet will be undergoing a procedure that requires sedation or anesthesia. There are risks involved with the use of any anesthetic agent, including, but not limited to prolonged recovery and death. In addition to the mandatory patient examination, having pre-anesthetic blood testing completed will help us to detect subclinical disease that may affect your pet’s ability to tolerate and recover from anesthesia. Having normal blood test results does not guarantee absence of risk, but being aware of any subclinical conditions may affect the decision to proceed or not and, if the decision is made to proceed, awareness of underlying conditions will allow us to tailor the anesthetic protocol to make the procedure as safe for your pet as possible.

Recommended Pre-Anesthetic Testing for Your Pet:

Pets under 1 year of age: CBC, Chem 10, Electrolytes - $95.75Pets 1-7 years of age: CBC, Chem 15, Electrolytes- $107.08Pets over 7 years of age: CBC, Chem 15, Electrolytes, T4 - $123.7

Procedural Risk:

While I accept that all procedures will be performed to the best of the abilities of the staff at ALL PAWS ANIMAL HOSPITAL, I understand that veterinary medicine is not an exact science and that no guarantee or warranty has been made regarding the results that may be achieved. Potential complications can occur with any anesthetic, surgical, or dental procedure. I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. My signature on this form indicates that any questions I have regarding the following issues have been answered to my satisfaction:

• The reasonable medical and/or surgical treatment options for my pet

• Sufficient details of the procedures to understand what will be performed

• How fully my pet will recover and how long it will take

• The most common and serious complications

• The length and type of follow-up care and home restraint required

• The estimate of the fees for all services

• Any necessary payment arrangements

For dental procedures, especially tooth extraction, additional complications might include fracture of the jaw, damage to the eye, and/or oronasal fistula formation.

I understand that during the course of the operations or procedures, unforeseen conditions may arise that may necessitate the performance of life-saving measures.

The hospital staff (initial one)HASDOES NOT HAVE permission to perform any necessary life-saving protocols and understand I am responsible for any additional costs that may be incurred. If cannot be reached or fail to select opt out above, I authorize ALL PAWS ANIMAL HOSPITAL to perform necessary services deemed fit by the Veterinarian.

Hospitalization:

In the event my pet is hospitalized beyond the first day at this facility, I understand that veterinary care during nighttime hours and/or weekends is provided at the discretion of the attending veterinarian. Continuous presence of personnel may not be provided during these hours. If I desire that my pet have supervision when the facility is closed, I elect to either provide care in my home or shall otherwise transfer my pet to a local emergency clinic where overnight veterinary supervision is available.

Additional Care:

In addition to the surgical procedure my pet is here for today, I would like the following services provided:

Vaccinations:

Dog:

RabiesDistemper (DHPP)LeptospirosisLymeBordetella

Cat:

RabiesDistemper (FVRCP)Feline Leukemia (FeLV)

Microchips:

Microchips are the best way to recover your pets when they become lost. ALL PAWS ANIMAL HOSPITAL offers this service for $42.00.

Would you like us to microchip your pet today? YesNo

I understand that I MUST pick up this animal on the day and time indicated by ALL PAWS ANIMAL HOSPITAL personnel. An overnight charge of $30 per night will be assessed to all owners who do not pick up their animal by 5:00 pm.

By submitting this form, I hereby confirm that the procedures to be performed have been fully explained to me to my satisfaction and I have read and understand the contents of this document.

Personal Belongings (leashes, collars, harnesses, carriers, toys, blankets, food, etc.) :

Please list everything you have brought with your pet today. ALL PAWS ANIMAL HOSPITAL will make every attempt to return your belongings. We cannot guarantee that they will not be lost, damaged, or forgotten.

WE ACCEPT VISA, MASTERCARD, DISCOVER, AMERICAN EXPRESS, CARE CREDIT, SCRATCHPAY, CASH, OR CHECK AS PAYMENT. PAYMENT IS DUE UPON RELEASE OF THE ANIMAL.