159 River Street  Rutland, Vermont 05701  tel. 802-773-4771  fax 802-773-3991
185 Main St  Ludlow, VT 05149  tel. 802-228-5700  fax 802-228-2041
Carol H. Gifford, DVM  Heath McNutt, DVM  Lisa Hickman, DVM
Date:
Patient:
Client:
Age:
Canine spay/neuter consent
Please read carefully and sign
Your dog is scheduled for a spay/neuter, and will be put under general anesthesia. Like you, our
greatest concern is his or her well-being. Before putting your pet under anesthesia, we will perform a full
physical examination. Your pet may have intravenous access and IV fluids as considered necessary by
the veterinarian, and will be closely monitored during and after anesthesia.
NOTE- Cardiopulmonary Resuscitation Policy
CPR is the combination of treatments required to save a life when a patient has suffered respiratory or
cardiac arrest. In the unlikely event of an anesthetic emergency, CPR will be administered to your pet to
the degree considered necessary by the veterinarian, including treatments, medications, diagnostics and
monitoring. Written consent from the owner must be given to request a "Do Not Resuscitate" order for
the above patient.
Optional recommended items are listed below. Please indicate your preference by marking the
provided line:
Pre-anesthetic bloodwork
Blood testing will determine proper kidney and liver function (essential to the elimination of anesthetic
agents) and adequate blood-clotting capability. Please note that the cost of the blood testing is NOT
included in the cost of any procedure.
_____
Mini- Screen: blood count and selected liver and kidney function test ($59.00)
_____
Full Wellness Profile: blood count, full range of standard chemistries and electrolytes ($104.00)
_____ Please do the pre-anesthetic screen the veterinarian feels is most appropriate.
_____ I refuse the recommended blood testing. I understand that there is always a potential risk associated with
anesthesia/surgery.
Pelvic (hip) radiographs
Many dogs suffer from hip dysplasia, which is a problem in bone development of the hip joints. Early diagnosis and
treament is essential in successful management of this disease. While your dog is sedated for surgery, we
recommend a screening radiograph (x-ray) for this disease. The cost of this screening test is $68.00- a 20%
savings off our usual price.
_____Yes, please screen my dog for hip dysplasia
_____No, I decline this test
Microchip administration
Help ensure that your beloved pet returns home if lost. Have your pet micro-chipped while under anesthesia for
$52.00- includes one year enrollment in Home Again's proactive recovery network.
_____Yes, please micro-chip my pet. ____My pet is already micro-chipped
_____No, I decline at this time.
Owner signature __________________________________________________________
Number where I can be reached today ________________________________________