2010 Arcadia Street
Fort Myers, FL 33916
Phone: (239) 332-2719
Fax: 239-332-4391
Owner Name _____________________________________ Phone Number__________________Client # ____________
Patient/Pet Name_____________________________
Cat/Dog (circle one)
Breed ___________________________
Color ___________________________________________Sex_________________________Age___________________
I understand that my pet will not be receiving a complete physical exam prior to surgery and to the best of my
knowledge does not have any health concerns at this time.
I understand that there is a risk of complications with every procedure or medications, including the possibility of death
as a severe complication of surgery, anesthesia, or other procedures. There is no guarantee as to the results of any
procedures, vaccinations, diagnostics or treatments.
I am the owner or the authorized agent for the owner of the animal described above and I have the authority to execute
this consent. I hereby give the veterinarian, the Gulf Coast Humane Society Veterinary Clinic and any authorized agents,
staff or representative’s consent and authority to perform the following procedures or operations:
___ Spay
___ Neuter
___ Microchip ($20)
___ Pain Reliever ($10-$15)
___ Antibiotics ($10-$25)
___ E-collar ($10-$15)
If your pet is 6 years of age or older, it is strongly recommended that we perform pre-anesthetic blood work to
determine that your pet can safely handle anesthesia. A full comprehensive blood work panel is $90.
___ Yes, please perform blood work on my pet.
___ No, do not perform blood work on my pet. I understand that this is against veterinary recommendations for senior
pets and my pet may experience anesthetic complications, including death.
___ I understand that all anesthetic procedures are done solely at the discretion of the attending doctor and
can be declined for any reason.
___ I was explained the importance of having an E-collar on at all times after surgery for at least 10 days or until doctor
advises.
The nature of these operations or procedures has been explained to me and I understand what will be done. I further
understand that during the course of the operations or procedures unforeseen conditions may arise that may
necessitate the performance of additional procedures. I authorize the use of appropriate anesthesia and pain relief
medication as needed before or after the procedure. I understand that hospital support personnel will be used as
deemed necessary by the veterinarian.
I certify that if I am signing as the owner or agent, I have authority to execute this consent:
Name (please print) _______________________________________________________________________________
Signed ____________________________________________________________ Date _________________________
HOSPITAL USE ONLY:
___Umbilical Hernia
___Inguinal Hernia
___Deciduous Teeth
___Undescended Testicles
___ Other