SPAY/NEUTER TREATMENT CONSENT FORM
OWNER OF ANIMAL
Name: ____________________
Address:___________________
__________________________
Phone: ____________________
PATIENT: _____________
BREED: ___________
SPECIES: ___________
AGE: ______
SEX: _______________
WEIGHT: _______
Color and markings: ________________
*All pets are required to be current on their vaccinations administered by a veterinarian. Dogs must
have their DAPP, Leptospirosis, Bordetella and Rabies vaccines. Cats must have their FPV and
Rabies vaccines. If your pet is not current or you can not provide documents showing the vaccines
were administered by a veterinarian we will administer the required vaccines.
Our economy spay and neuter fees include the following:
1. A pre-surgical exam-the Veterinarian will listen to the heart and lungs, check the gums to make
sure that your is not dehydrated or anemic, the temperature and weight will be checked as well to
make sure your pet is within a healthy and normal range.
2. The surgery is performed under gas anesthesia using isofluorane
3. Your pet will be monitored with a pulse oximeter which monitors the oxygen level and heart rate
4. 3 injections of pain medication will be administered which will last a total of 24 hours
5. The surgery itself
6. Pain medication to go home with your pet to be given for 3 days
Surgery Fees
Neuter
Spay
Cat
99.50
119.50
Dog
0-24lb
169.50
199.50
25-49lb
179.50
219.50
50-74lb
189.50
249.50
75-99lb
199.50
279.50
99-124lb
229.50
309.50
> 124lb
259.50
349.50
There will be an additional fee for males if both testis are not in the scrotum (cryptorchid) or for
females that are in heat, pregnant, obese or have any other abnormalities.
It is our goal to keep spay and neuter surgeries as reasonably priced as possible to encourage
everyone to have this important surgery done. Our base price includes the services that we feel are
the most important for a successful surgery and a comfortable experience for your pet. There are
several other services that we feel are important to offer. They are available at an additional fee.
1. Laser upgrade-The CO2 laser seals as it cuts. This results in minimal bleeding as many of the
vessels are sealed. The nerve endings are sealed as well so they transmit less pain sensation.
This results in a smoother, less painful recovery period with less tissue damage.
Cat $19.50 yes_____
no_______
Dog $29.50 yes_____
no_______
2. Elizabethan collar-This is the lamp-shade looking device that goes on your pets neck to help
prevent licking/chewing of the incision site. Not all pets need this but it is handy to have available in
case your pet starts doing this at a time when you can not come by to purchase one.
$9.75-19.75 yes ______ no______
<first-name>
<last-name>
<animal>
3. IV catheter and IV fluids-The IV catheter provides quick access to the veins in the case of an
emergency. The fluids help keep the blood pressure at a normal level and help to protect the
kidneys and liver during surgery. They also can help your pet wake up from anesthesia more
quickly. We continue the fluids throughout the surgery and recovery period.
$79.75 yes_____
no______
4. Microchip-Although this can be installed any time, it involves a fairly large needle so if done while
your pet is under anesthesia and already getting pain medication the procedure is more comfortable.
Our microchip includes lifelong registration. Our regular price for the microchip is $29.50, if it is done
today under anesthesia there is a $5.00 saving.
Chip $24.50 yes_____
no______
5. Pre-anesthestic blood testing- We recommend a blood screening test before anesthesia. The
tests look for problems like anemia, diabetes, kidney and liver disease. $89.50 - $159.50 depending
on the health and needs of your pet as determined by our vet. Pets that are 7 years and older are
required to have a blood screening prior to anesthesia.
yes_____ no_____
6. Sedatives for home – In order to keep your pet calmer during the 2 week recuperation period we
can send home sedatives. $14.75
yes_____ no_____
7. Nail Trim $6.75 (reg. $12.75) yes _____ no _____
What (if any) medicine is your pet currently taking & when was last
dose?___________________________________________________________________________
I certify that I own the above described animal and authorize the Fire Mountain Veterinary Hospital to hospitalize said
animal. During this time they may administer vaccinations, medication, tests, surgical procedures, anesthetics, or
treatments they deem necessary for the health, safety, and well being of my pet while under the care and supervision of
the hospital. I understand that there are inherent risks associated with anesthetic, medical, and surgical procedures,
including death. I authorize the doctors of the Fire Mountain Veterinary Hospital to initiate care to address these
complications should they arise while under their care. In the event of an emergency, the hospital will make every
reasonable attempt to contact me so that I am aware of the situation, so that I am involved in medical decisions. The
contact phone numbers in the chart are correct. If my pet should injure itself in an escape attempt, refuse food, soil itself,
become ill, or die while in the hospital, I will hold the Fire Mountain Veterinary Hospital and the staff free of all
responsibility and/or liability in the absence of gross negligence. I understand that veterinary staffing is not provided
overnight and I am aware that my pet will be unattended during this time. I am aware that there are veterinary hospitals
open overnight but I elect to leave my pet at the Fire Mountain Veterinary Hospital instead of pursuing a transfer.
I further realize that I am responsible for payment of all above mentioned procedures/treatments in full at the time of my
pet is discharged. If I neglect to pick up the animal within fourteen (14) days of notice that it is ready for release, the Fire
Mountain Veterinary Hospital may assume that the animal has been abandoned per sec. 1834.s of the California legal
code. In such instances, the Animal Hospital is then authorized to dispose (adopt) of my pet as they see fit.
Abandonment, however, does not release me of my obligation for payment of said bill.
I further agree that in case of non-payment, to pay a finance charge of 1.5 percent per month (18 percent per annum), a
$2.00 month billing charge and any and all collection and attorney’s fees incurred by the Fire Mountain Veterinary
Hospital relating to this manner.
Signature:______________________________________________________________________
Phone number contact for treatment day: ___________________________________________
SPAY/ NEUTER
<first-name>
<last-name>
Weight_______ Temp_______ Check In Tech:_________
<animal>
DR.___________
TECH____________
Current Meds Pet is taking:_______________________________________________________________
PRE ANESTHETIC INJECTIONS
□
□
□
MORP______SQ / IV/ IM
ACE_________
SQ
TORB________SQ
□
KET _________IM/ IV □
DOM _______IM/ IV □
MIDAZ________IM/ IV
□
PROPOFOL ________IV □
MET_______________ PO □
BUP ____________IM/ IV
ELECTED SERVICES: (TECHS CIRCLE Y OR N)
□
ECOL/ SIZE _______Y / N □ STAT__________Y / N □
LASER________Y / N
□
IV + RATE_________
TNT
□
Y/N□
_______Y / N
CHIP
(STICKER HERE)
MEDICATIONS TO GO HOME
MET 0.05 ml_____________________
0.10 ml_____________________
0.15 ml_____________________
OTHER:____________________
ACE 10mg_____________________
25mg_____________________
OTHER MEDS
CAR 25mg______________________
75mg______________________
100mg_____________________
_______________________________________
IN HEAT?
YES
□
NO
□
VACCINES? (TECHS CIRCLE IF NEEDED)
□
□
K9: DPV_yr
LEPTO yr
RV__yr
DEWORMING?________________Y/N
□
BVIN1
□ FELINE: FPV__yr□
□
RV__yr
□
LV1
□
____□
HWT?_______Y / N
I.C.?
PREVENT?__________________(
)M
ADDITIONAL NOTES:__________________________________________________________________
_______________________________________________________________________________________
______________________________________________________________________________________
POST OP CALL________
□
_____□
CHARGES IN