Surgical Consent Form
Owner’s Name:________________________ Date: ______________
Pet’s Name: _______________ Breed: _____________ Sex: _________ Age: __________
Emergency Contact Phone Number:_____________________________
Procedure or Surgery Today:____________________________________________
I understand that all anesthesia involves some minimal risk to my pet and therefore the technicians and/or doctors
will not be held liable or responsible in any manner for the injury, escape, or death of my pet in connection with the
procedure. I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before
the procedure(s) is/are initiated.
Anesthesia carries some risk therefore we always REQUIRE blood work for all pets over 8 years of age prior to
anesthizing your pet. If your pet is under 8 years of age, the doctors RECOMMEND a blood screen to check for
existing liver or kidney problems, anemia, high or low blood sugar prior to anesthesia. I understand the importance of
Pre-Anesthetic Blood Testing and choose this for my pet at an additional cost of $78:
Yes_____
No______
We also highly recommend intravenous fluids for all procedures requiring anesthesia at an additional cost of $50:
I understand the importance of intravenous fluids and choose this for my pet:
Yes______
No______
As part of a complete pre-anesthetic wellness screen we offer an additional x-ray at a reduced rate of $20 to scan for
any internal masses or other radiographic abnormalities. Would you like a radiographic scan of your pet?
Yes______
No________
Elizabethan Collar is available to ensure that your pet will not lick/ bite/chew or otherwise disrupt a healing surgical
site. This small investment could save you the added cost to have the site repaired. Average cost is $10-$18.
Would you like a collar sent home with your pet?
Yes______
No_______
If your pet is here for a dental procedure, may we extract any infected or abscessed teeth for an additional cost per
tooth?
Yes______
No_______
I understand by initialing that if during surgery, my pet is found to be in heat or pregnant there will be an additional
charge of $35. __________
I understand by initialing that my pet will be inspected for fleas, upon admission, and treated if any are found present
at an additional cost of $8- $10 before proceeding with the procedure. ________
The following list displays options available to your pet while he/she is under anesthesia:
Nail Trim $13 ________ Anal Sac Expression $15 ________ Ear Cleaning $19.84 __________
Micro-Chip by Home Again $52 __________ We pay for the first year (value $14)
I, being responsible for the above animal, have the authority to grant you my consent to receive treatment, prescribe
for and/ or operate upon my pet as noted above, and I thoroughly understand and assume all risks. I agree to pay in
full for the services rendered.
_________________________________
Signature of Owner or Agent
_________________
Date