Greys and Strays LLC
Alysia Deaven VMD 717-304-9987
Surgery and Anesthesia Consent Form
YOUR NAME_____________________________________ PHONE: ________________________
ADDRESS/CITY/ZIP:___________________________________________________________________
_____________________________________________EMAIL:_________________________________
PET NAME: ____________________ __________BREED:______________________________
AGE/BDAY;:___________________SEX________WT:_____________COLOR:____________________
LIST ALL CURRENT MEDS:____________________________________________________________
Anesthetic and medical or surgical procedure(s) and services to be performed:
_________________________________________________________________________________
_________________________________________________________________________________
Ketamine/Midazolam:_________Rimadyl inj:_________Previcox:________________Bup:___________
Isoflurane gas:____________________________________________________________________
Surgery time:_______________________________________________________________________
Other:______________________________________________________________________________
_________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Hospitalization/Surgical Information
Preparation—The skin around the surgical area will be clipped and scrubbed with an antiseptic. We follow
sterile procedures (surgical preparation, surgical packs).
Anesthesia—Pre-surgical bloodwork and physical examination will enable us to assess and minimize the risk
of anesthesia for your pet. While anesthesia is not totally risk-free, the risk has been greatly reduced by
improved anesthetic drugs, monitoring equipment and increased veterinary expertise.
Monitoring—We further minimize anesthetic risk by monitoring heart rate and rhythm, respiration rate and
quality, oxygenation, and depth of anesthesia during the procedure.
Catheterization—For some surgical procedures, an intravenous catheter is placed to provide us with an easy
route to administer medications and fluids (which support kidney function and blood pressure) during the
procedure.
Pain Management—We will proactively manage pain associated with any procedure with appropriate pain
management medications. As with any drug, side effects may be associated with their administration.
Authorization and Risk Assessment
I, the undersigned owner or agent of the owner of the pet identified above, certify that I am _____ I am not
______ (check one) eighteen years of age or over and authorize the veterinarian at Greys and Strays, LLC to
perform the above procedure(s), anesthesia and surgery on my pet. I understand that some risks always exist
with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks
with the attending doctor before the procedure(s) is/are initiated. My signature on this consent form indicates
that any questions have been answered to my satisfaction.
While I accept that all procedures will be performed to the best of the abilities of the staff at this facility, I
understand that veterinary medicine is not an exact science and that no guarantee or warranty has been
made regarding the outcome of this/these procedures and the results that may be achieved.
I authorize Greys and Strays, LLC to perform any additional diagnostic, treatment or surgical procedure(s)
deemed necessary for medical or surgical complications or otherwise unforeseen circumstances. While
Greys and Strays provides the highest quality of anesthesia monitoring and surgical services, I understand
that there are rare complications associated with any anesthetic or surgical procedure. No warranty or
guarantee has been given to me as to the results or cure afforded by these treatments or procedures.
I fully understand these risks and understand that the veterinarian will try to minimize such risks. I will not
hold Greys and Strays or any staff member liable for any complications that may arise.
I accept that veterinary medicine is an inexact science and that no guarantee of successful treatment has
been made. I have read and understand the nature of the above procedures and accept the specific terms
and conditions set forth herein. I acknowledge that I am responsible for payment in full at discharge.
I HAVE READ AND FULLY UNDERSTAND THIS SURGERY AND ANESTHESIA CONSENT FORM.
 I have not given my pet any food after 12AM, unless otherwise advised by my doctor. I understand that
this is important for anesthesia safety.
(______)_______________________
(_____)______________________________
PHONE NUMBERS FOR TODAY/EMERGENCY NUMBERS
____________________________________________
SIGNATURE OF OWNER/AUTHORIZED AGENT
________________________________
DATE
1: PRE-OP BLOOD SCREEN FOR ORGAN AND BLOOD CELL FUNCTION
It’s our job to ensure that your pet can process and eliminate the anesthesia given and tolerate pain meds. Before we
perform a procedure requiring anesthesia, we can run tests to confirm that your pet’s organs are functioning properly.
We may also detect hidden health conditions or potential problems that we could treat early, provide baseline levels
for the future, and evaluate your pet’s health up front so we can avoid problems related to anesthesia. If preanesthetic
results are within normal limits, anesthetic risk is minimized. If results are abnormal we can change the anesthetic
protocol, take precautions to safeguard your pet’s health and reduce the risk of potential complications or reschedule
surgery after more bloodwork or diagnostics are performed. The preanesthetic panel includes kidney and liver
function, glucose, and protein level. The General Chemistry Panel incl the preanes panel along with biliary system
function, pancreatic values, cholesterol, phosphorus and calcium. The Complete Blood Count or CBC incl red blood
cell, white blood cell and platelet counts. The Electrolytes incl Sodium, Potassium and Chloride.
RECOMMENDED FOR ALL ANIMALS; REQUIRED OVER 5 YRS , DENTALS
I DO  I DO NOT
authorize the Preanesthetic panel $40
I DO  I DO NOT
authorize the Complete Blood Count (CBC) $35
I DO  I DO NOT
authorize the Preanesthetic panel, CBC and Electrolytes $90
I DO  I DO NOT
authorize the General Chem panel and CBC $125
I DO  I DO NOT
authorize the General Chem panel, CBC and Electrolytes $150
I DO  I DO NOT
authorize the General Chem panel, CBC, Lytes and Thyroid $175
2: INTRAVENOUS FLUID ADMINISTRATION
IV Fluids help to support kidney function during anesthesia and maintain hydration. They also give us
rapid access in the case of an emergency. We need to clip the leg and place an IV catheter for fluid
administration. It is recommended for ALL animals undergoing anesthesia. REQUIRED FOR DENTALS
AND DOGS OVER 5 YRS OF AGE
I DO
I DO NOT 
AUTHORIZE IV FLUIDS FOR $30.00
3: HEARTWORM TESTING/HW PREVENTION: HEARTWORM IS IN THIS AREA!!!!!!
Heartworm disease, which is transmitted through the bite of an infected mosquito, can affect all dogs since
mosquitoes travel into our homes. This disease is easy to prevent, but very difficult and expensive to treat.
The 4DX test from IDEXX takes 10 minutes to run and will show if your pet is Heartworm, Lyme,
Ehrlichia or Anaplasmosis positive. Heartworm prevention is recommended for all dogs for life.
I DO 
I DO NOT  AUTHORIZE THE 4DX HEARTWORM TEST FOR $40
I WANT TO START MY DOG ON HEARTGARD PLUS
(cost is weight dependent)
4: DEWORMING; FECAL TEST; GIARDIA TEST
All dogs and cats should have a fecal performed at least once a year
I DO  I DO NOT  WANT A FECAL EXAM $20; I DO  I DO NOT  WANT GIARDIA TEST $25
I DO WANT
DRONTAL  PYRANTEL PANACUR (cost is weight dependent)
5: MICROCHIP WITH REGISTRATION: A HOMEAGAIN chip can be inserted under the skin between
the shoulder blades to identify your pet if lost or stolen and to suffice as a LIEFTIME LICENSE!!
I DO 
I DO NOT  WANT A MICROCHIP FOR $35.00
6: POST OP LASER THERAPY: The Companion Therapy Laser uses light to stimulate the cells that
causes photobiomodulation-the cells increase their fuel production needed for repair and this allows for
quicker healing, pain reduction and decreased inflammation and swelling. The cost for this after the spay or
neuter is $10.00
I DO
I DO NOT
WANT LASER TREATMENT
7: ELIZABETHAN OR ECOLLAR:REQUIRED An ECollar will prevent your dog from licking after surgery.
IF you already have an ecollar please bring it to check in on surgery day. An INFLATABLE or BITE NOT collar can be
purchased in a pet store if your pet does not like the Ecollar
8: PAIN MEDS TO TAKE HOME: REQUIRED
All dogs receive pain medication prior to surgery that will last for 24 hours. Surgical procedures require additional
medication at home to make your pet more comfortable, less painful and actually heal faster. Dogs with extractions
will likely get 2 types of post op pain meds. Pre-anesthetic bloodwork is RECOMMENDED FOR ALL dogs
receiving pain meds.
9: IV CATHETER is REQUIRED (If you opt for IV fluids, this 10.00 catheter cost is removed.)
SIGNATURE: ________________________________ DATE: _________________________
I HAVE READ AND FULLY UNDERSTAND THE DISCHARGE INSTRUCTIONS:__________________