Metz Petz Veterinary Clinic
Canine Surgical Check In and Consent Form
Client’s Name______________________________ Patient’s Name________________________
Anesthesia/Surgical Procedure(s) to be performed___________________________________________
Has your pet ever had a seizure? Yes No
Has your pet eaten in the past 12 hours? Yes
No
Does your pet have any known allergies? Yes No
Is your pet experiencing any other problems?________________________________________________
Is your pet on any current medications? ____________________________________________________
Your pet is being admitted for anesthesia/surgery at Metz Petz Veterinary Clinic. To minimize the likelihood of
complications during anesthesia, we recommend that your pet receive a pre-anesthetic blood screen to detect
potential health problems. Please circle
Bloodwork:
Coag Panel (clotting times)$35 Safety Pack(Chem,CBC) $60
Safety Pack + $90
(Mininum Safety Pack is required for all patients over the age of 7 years)
I decline all bloodwork (initial)____________
Comfort Package: All of our patients receive pain management for 24 hours. This
package includes medication to be given at home post surgery for 3 days. Cost $12.00
Approve
Decline
Fluoride Application: Most beneficial when applied during your pet’s first 18 months
Applied to help harden the enamel to help prevent dental disease. Cost $15.00
Approve
Decline
Approve
Decline
Approve
Decline
recommend a yearly fecal or deworming. Fecal: $30 Dewormer: Cost dependant on weight. Approve
Decline
Ear Cleaning: Your pet’s ears can be thoroughly cleaned under anesthesia. Cost $9.00
Approve
Decline
Approve
Decline
Dental Touchup: The teeth can be scaled, polished and have fluoride applied under
anesthesia at a reduced rate (compared to a dental procedure alone). Cost $62
Microchip: While your pet is under anesthesia, a permanent I.D. chip can be
painlessly implanted under the skin. Cost $50.00 (which includes a 1 year registration.)
Fecal/Deworm: To prevent the spread of parasites to our pets and family members we
Anal Gland Expression: If your pet has been scooting this could be due to full anal
glands. Your pet’s anal glands can be expressed while under anesthesia. Cost $6.00
Vaccinations to be given today?
Rabies
Bordetella
DA2PPC/DA2PPCL4
Lyme
Heartworm: If your pet has not been tested in the last 6 months and currently not on prevention, we highly
recommend testing today. Would you like us to test today? Yes
No
* If your pet has fleas, he/she will be given a Capstar to prevent the spread to other pets. Cost $7
I authorize the doctor(s) at Metz Petz Veterinary Clinic to perform the above anesthetic and surgical procedure(s)
described above. I understand that some risks always exist with anesthesia and/or surgery and I am encouraged to
discuss any concerns that I have. While I understand that all procedures will be performed to the best of the
abilities of the staff at Metz Petz, I understand there is no guarantee regarding the results that may be achieved. I
also understand that all charges will be paid in full at the time of release.
Owner Signature _____________________________________________________ Date ____/____/____
Contact Number _________________________________
Witness______________
Do you need a refill of current medication or prevention today? Type and amount:
_________________________________________