Employee: _______
Oregon Spay/Neuter Fund Program
Consent Form
Date____________
WT: _______
Temp: _______
Client ID: ________________
Owner’s Name____________________________________ Phone #_______________________________
Pet’s Name: ________________________ Species: K9
FELINE
Sex: M
F
* Oregon law mandates the use of pain medication for ALL pets having surgery. All pets will receive the BRONZE pain
relief package for this surgery. Our induction anesthesia contains an opiate that will assist in pain relief for the first 24 hours
after your pet’s surgery. All pets will also receive a NSAID given in hospital. This medication will last five days for cats and
24 hours for dogs. The fee for this required pain relief package is $10.00 (additional pain relief packages
recommended and listed below).
*All pets with fleas will be treated at owner’s expense. The fee is $14.50.
COMP SURGERY EXAM
COMP SURGERY EVAL
HEALTHCARE MAINT. EXAM
I understand the above mandatory requirements ______________ (Initials)
Optional services available and recommended
ACCEPT
DECLINE
BLOOD SCREEN- $43.52
Tests liver and kidney functions to help ensure safety
of your pet while under anesthesia
*Fractious pets may need to be sedated in order to get sample.
_________
_________
ADDITIONAL MONITORING - $40.13
ECG - Electrocardiogram detects abnormal electrical activity in the heart
_________
Blood Pressure Monitor – monitor that closely watches blood pressure of
patient while under anesthesia, quickly detects drops or spikes in blood pressure.
_________
GOLD PAIN RELIEF PACKAGE (OPTIMAL) –
K9 - Additional sustained release opiate given in-hospital (lasts 3 days)
NSAID to go-home (5 day supply) and laser therapy. $56 - $82
Feline – Additional sustained release opiate given in-hospital (lasts 3 days)
and laser therapy. $51.84
_________
_________
SILVER PAIN RELIEF PACKAGE
K9 – Additional NSAID to go-home (5 day supply)$30-$55 (dep. on weight). _________
Feline – Additional opiate given in hospital (lasts 12 hours) $23.92
_________
IV CATHETER AND FLUIDS - $60.70
Anesthesia/sedation lowers blood pressure and decreases
blood flow to vital organs. This option decreases risk during surgery.
Fluid administered IV.
_________
_________
_________
_________
SUBCUTANEOUS FLUIDS – $31.86
Anesthesia/sedation lowers blood pressure and decreases
blood flow to vital organs. This option decreases risk during surgery.
Fluid administered under skin.
MICROCHIP – $30.16
This chip then holds your pet’s identity for
life. If your pet is ever lost or stolen veterinary practices and shelters
scan for a microchip before adoption or euthanasia.
____________
___________
E-COLLAR - $8.96 - $13.00 (dep. on size)
_________
_______
EXTRACT IMPACTED DECIDUOUS TEETH - $18.40ea
________
______
DEWCLAW REMOVAL - $39.03ea or $78.07ea
________
______
UMBILICAL HERNIA REPAIR- $74.83
________
______
RETAINED TESTICLE - $40.02 or $70.13
_________
________
RECOMMENDED ROUTINE CARE
By de-worming your pet you are protecting your family.
10,000 children alone are affected annually by roundworms transmitted by dogs and cats, 1,000 of who
lose their vision as a result.
CANINE DEWORM/PPM2 –
Oral liquid that treats for roundworms,
Hookworms, whipworms and tapeworms
$31.43(2 doses)
_________
_________
FELINE DEWORM/PP2 Oral liquid that treats for roundworms,
Hookworms and tapeworms
$24.01 (2 doses)
_________
_________
FELINE DEWORM/PROFENDER Topical solution that treats for roundworms, hookworms and
Tapeworms
$13.38-$19.56
_________
_________
VACCINES-
Cats
Fvrc2p/Felv
______3wk/1yr
Rabies
______1yr/3yr
FIV (test req.) ______2wk/1yr
FIP
______3wk/1yr
ADDITIONAL SERVICESFIV/FeLV Test
Heartworm, Lyme, E. Canis Test
Dental Club Dental
Dogs
DHLPP/Corona
Rabies
Bordetella
Lyme
Influenza
______3wk/1yr
______1yr/3yr
______3wk/6mo
______3wk/1yr
______3wk/1yr
__________
__________
__________
Feral Cats – Ear tipped at no additional charge
_____ YES _____ NO
Medication given within 30 days: _____________________________________________
Medical conditions/concerns: _________________________________________________
I understand that there are some risks under any anesthetic, but will hold Village At Main
Veterinary Hospital in no way responsible under any circumstance. I thoroughly understand
the information on this sheet is correct and by signing below, I understand and accept the
policies of the hospital.
AUTHORIZATION______________________________________________________