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Client verification of information:

Date

Patient Name *

Name *

First

Last

Phone Number *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email Address *

Pet verification of information:

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Name *

Species *

Sex *

Breed *

D.O.B / Age *

Color *

Surgical Consent Form Canine

Procedure(s) to be performed: *

As with any procedure requiring general and/or local anesthesia, there are certain risks that serious complications or even death may result. To minimize the risk of such occurrences, we offer baseline bloodwork be performed in order to assure proper organ function, clotting ability, detect anemia or infection, baseline for future reference. The complete blood count (CBC) is a more sensitive indicator of disease than the physical exam. Additionally, white blood cells (WBCs) and platelets can change within hours due to acute infectious diseases. Abnormal glucose levels can increase anesthetic risk and differ markedly between fasted and non-fasted samples, breeds, age, and sick and healthy patients. Evaluating electrolytes, hematocrit and total protein in fasted patients is essential for monitoring during anesthesia, minimizing the risk of arrhythmias and hypotension, and facilitating patient recovery. I also am aware that my pet will not be supervised overnights and from Saturday afternoon until Monday morning as staffing is not here. The doctor may be in and out of the facilities periodically with providing treatments to patients and/or emergency calls. I further acknowledge and understand that Decatur Veterinary Clinic is not equipped with an Emergency Fire Protection Sprinkler System.

Please only choose ONE selection *

I DO want a basic CHEMISTRY PANEL ONLY to be performed for $65.00.
I DO want a FULL CHEMISTRY PANEL/ELECTROLYTE/CBC to be performed for $125.00.
I DECLINE any bloodwork to be performed.

HISTOPATHOLOGY: If the surgery to be performed today is a tumor/mass removal or biopsy, would you like to send the sample to TVMDL for analysis and diagnostics?

Please only choose ONE selection: *

This DOES NOT APPLY to my pet.
I DO want to send the sample to the lab for testing at a price of $150.00.
I DO NOT want to send the sample to the lab for testing.

***Post surgical options: (ADDITIONAL COST)***

[IF NOTHING IS SELECTED, SERVICES WILL NOT BE PERFORMED]

E-Collar: *

I DO want an E-Collar
I DO NOT want an E-Collar
I have an E-Collar at home and will bring it with me at discharge

Would you prefer a Zen Collar (inflatable) or Plastic Collar? *

Zen Collar
Plastic Collar

Pain Medication: Post surgical pain medication. *

I DO want an injection of pain medication given to my pet immediately after surgery in addition to pain medications sent home.
I DO only want pain medication sent home.
I DO NOT want Pain Medication.

Nail Trim: Would you like to have a nail trim performed while sedated for $10.00? *

I DO want a nail trim.
I DO NOT want a nail trim.

Heartworm Test: Vector borne in house test that looks for Heartworms, as well as 3 tick diseases, Ehrlichia, Anaplasmosis, and Lyme Disease. $25.00 *

I DO want a heartworm test.
I DO NOT want a heartworm test.

Vaccines: DHLPP Rabies Influenza Bordatella Rattlesnake *

I DO want vaccines given.
I DO NOT want vaccines done.

Vaccines that need to be done are:

Anal gland expression. $12.00 *

I DO want anal glands expressed.
I DO NOT want anal glands expressed.

Microchip. $40.00 *

I DO want a microchip and will fill out the appropriate paperwork for that in clinic on arrival.
I DO NOT want a microchip done.

Authorization *

As the owner of the above pet, I certify that I am over the age of 18 and I authorize the staff of this hospital to perform the procedure(s) listed above, as well as those deemed necessary to treat life-threatening emergencies. As with all anesthetic, treatment, and/or surgical procedures, I understand there are risks inherent in these services. I acknowledge that staff members at this practice have explained the procedures to me, answered questions to my satisfaction and cannot be held responsible for any unforeseeable results. Further, I understand that I am financially responsible for all costs incurred during this surgery, treatment, and hospitalization.

Authorization *

While I accept that all procedures will be performed to the best of the abilities of the staff at this facility, I understand that veterinary medicine is not an exact science and that no guarantees have been made regarding the outcome of this/these procedures. I have read and understand the nature of the above procedures and accept the specific terms and conditions set forth herein.

Authorization *

I understand that any animal left over 24 hours after surgery will be charged an additional $25.00 per day. I also understand that most surgeries are required to stay overnight.

Authorization *

I acknowledge that I am responsible for payment in full for the above procedures and treatments at the time my pet is discharged.

Signature *

Clear Signature

Date *

Canine Surgical Consent Form