Bastrop Veterinary Hospital
P.O. Box 625, Bastrop, TX 78602
512-321-5386 / 512-303-6969
Owner Consent for Medical or Surgical Treatment
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Owner
Patient
Weight
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Surgical Procedure or Treatment
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Date
I authorize the veterinarians of Bastrop veterinary Hospital to perform the above procedure
and any treatment procedures deemed advisable or necessary for my pet. We recommend a
blood profile to ensure that your pet is in low risk category prior to anesthesia. Results of these
tests will help to determine your pet’s readiness for surgery. Depending on the results, we may
adjust the does or type of anesthetic used or advise fluid therapy or delaying of surgery. All
surgical procedures do include risks with anesthesia.
□ Flea and tick treatment
$20.00-30.00
ALL ANIMALS ADMITTED MUST BE CURRENT ON VACCINATIONS AND MUST BE FREE OF EXTERNAL PARASITES. ANY
ANIMAL FOUND OT HAVE FLEAS OR TICKS WILL BE TREATED AT OWNER’S EXPENSE.
□ Fecal analysis
$25.00
Determines the internal parasite status
□ Heartworm test
$33.00
Very accurate test for adult heartworms
□ Combo Test: Feline Leukemia/FIV
$47.50
This blood test will determine the presence of feline immunodeficiency virus (AIDS) and feline leukemia virus
□ CBC – Required for all spays and canine neuters
$49.75
A complete blood count assesses anemia, infection, and possible clotting problems. Low platelets can indicate a
serious problem related to bleeding during or after surgery.
□ Pre-anesthetic Chemistry 10 Profile
$49.50
This profile includes 6 chemistries that screen for kidney disease, liver disease, and diabetes
□ General Chemistry 15 Profile
$82.00
This profile includes 12 chemistries that provide in-depth screening for kidney disease, liver disease, diabetes,
gastrointestinal disease, pancreatic disease, dehydration, and an indicator of certain types of tumors.
□ I decline lab work at this time
□ Post-surgical pain management
$17.50+ injectable
Duration for canine – 1 day
Duration for feline – 3 days
$15-$30 Dependent on size (take
home)
While under anesthesia it is an opportune time to do other procedures. I authorize the below
procedures for my pet:
□ Vaccines
$16.50
□ Nail Trim
$95-$125 (does not include extractions)
□ Dental Cleaning (if not primary surgery)
□ Antibiotics if medically necessary
□ Ear cleaning (simple)
□ Microchip/I.D. chip
$40.00-$50.00
$54.50
Special Instructions:
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I understand that I assume financial responsibility for all services rendered, and
that payment is due on the date of surgery. Any medications and supplies
purchased will be at an additional charge. If we are unable to reach you at the
emergency contact number you have provided, we will do what is medically
necessary at owner’s expense.
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Owner signature/Responsible party
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Emergency contact numbers
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Date