Howard Springs Veterinary Clinic
Consent to Treatment and/or Anesthetic
Owners Name_____________________________________________________________________________________
Pet’s name________________________ Age_________ Sex________ Breed _____________Weight______________
The phone number where you can best be contacted on the day of surgery______________________________________
TREATMENT or PROCEDURE REQUIRED
□ Remove lump ________________________ □ Biopsy □ Ear Clean □ Aural Haematoma
□ X-Ray __________________________________ □ Stitch Up ________________________
□ Other_________________________
 SPEY (female)
 CASTRATE (male)
Is the animal on Heat or Pregnant
YES 
NO 
If yes - a surcharge of $75.50 will apply or if during surgery the veterinarian deems that your animal is
actually in season or pregnant the surcharge will apply.
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Has your pet been feed in the last 12 hours
YES 
NO 
Is your pet allergic to any medications or drugs that you are aware of
YES 
NO 
Are you currently giving your pet any medication
YES 
NO 
If yes -what medication is being given ____________________________________________________
 Is your pet currently being treated for fleas/ticks
YES 
NO 
 I agree that should flees or ticks be found on my animal whilst in your care it may be treated at my expense.
 We do recommend an Elizabethan collar depending on the type of surgery to prevent licking and chewing at
wounds and surtures this will be supplied at an additional cost of approximately $15.00.
 Your pet may require a pre-anaesthetic blood screen prior to surgery at a cost of $110.00 this is to check
kidneys and liver before we proceed with the anaesthetic.
 Should your pet require IV fluids during surgery to maintain blood pressure and to promote recovery this will
be an additional cost of approximately $96.80
I understand that the costs associated with the surgery are an estimate only and should not be seen at a definitive final
cost. There may be ongoing costs for antibiotic or other drugs or ongoing post-operative care or complications.
Please discuss any concerns regarding the ANESTHETIC RISK that your animal could face with the veterinarian
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I am authorised to present this animal for treatment and I consent to the above treatment being performed on the above animal.
I confirm that to the best of my knowledge the above details are correct.
I agree that I have read the above and have been given the opportunity to discuss any aspects I am not sure of with the
veterinarian or nurse.
I understand that the quote is an estimate only.
I understand that if my account is in arrears at any time I will be charged an account fee of $5.50 per fortnight and I agree to pay
said account keeping fee.
I understand that if I have not contacted the clinic within 48 hours of being asked to do so, or have not collected this animal
within 48 hours of being advised to do so, the animal will be regarded as abandoned and its future will be decided by the senior
veterinarian. Options will include re-homing, RSPCA or euthanasia. I understand I will be responsible for all costs of treatment
and hospitalisation even if I do not collect the animal from the clinic.
I agree to indemnify Howard Springs Vet Surgery and/or any staff member in the event of loss or liability that may arise during
the treatment of my animal.
Payment is required in Full on Discharge of Patient
How will you be paying for this procedure
Cash 
Cheque 
Signed__________________________________________________________
Eftpos/Credit Card 
Date _________________________
VETERINARY USE ONLY
Is animal being admitted as an emergency YES / NO
Fluid Therapy Recommended No / Yes
Pathology / Blood Test Recommended: No / Yes