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Surgery/Anesthesia Consent Form

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Surgery/Anesthesia Consent Form

Client Name*
First Last
Patient Name*
Patient Age*
Procedure*
Date*
MM slash DD slash YYYY
My pet is up-to-date on vaccinations.*
- Yes
- No
Parasite Consent*
I understand that if external parasites (i.e. fleas, ticks, etc.) are present at the time of admittance to hospital, my Pet will be treated according to the doctor’s recommendations at an additional cost to me.*
My pet is currently receiving heartworm prevention or has tested negative within the past 30 days.*
If pet is not currently on heartworm prevention, we will perform a heartworm test.
- Yes
- No
Are there any specific problems that need to be checked today?*
You will be charged the full physical exam.
- Yes
- No
Please state concerns.*
Did your pet eat this morning?*
- Yes
- No
Is your pet allergic to any drugs?*
- Yes
- No
List drug allergies.*
Is your pet currently on any medication?*
- Yes
- No
List medications.*
Anesthesia Consent*
I understand the procedure to be performed requires use of anesthesia.
I give permission for the performance of any life-saving procedures deemed necessary by the attending veterinarian.*
- Yes
- No
For Reproductive Procedures
- (Males) I understand there will be an additional charge if both testicles are not located in the scrotum.
- (Females) I understand there will be an additional charge if my female animal is in heat, pregnant or severely overweight.
NOTE: Each of these scenarios requires additional time and materials.
Reproductive Consent*
I understand the statement above.
Consent*
I understand and accept the risks and financial responsibility for my pet related to this procedure in accordance with the elections above.
Electronic Signature of Pet Owner/Authorizing Agent*
How would you like us to contact you today?*
- Phone Call
- Text
- Email
- Other
Email*
Phone Number*
Other Contact*
Please be sure to be available for some communication throughout the day as we may be calling while your pet is under anesthesia.
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