NORTHAMPTON VETERINARY CLINIC
ANESTHETIC/SURGICAL PROCEDURE CONSENT FORM
CLIENT_________________________
DATE______________
PATIENT_____________________________
PROCEDURE______________________________________
I certify that I am the owner, or authorized agent of the owner, of the above named animal and have the
authority to authorize treatment. I do hereby consent and authorize Northampton Veterinary Clinic and its staff
to hospitalize my companion animal to perform the above procedure(s). I understand that some risk of adverse
effects always exists with medical and surgical treatments. Adverse effects may include, but are not limited to,
infection, neurologic disease, cardiovascular disorders, metabolic disease, disfigurement and, rarely, death. I
also understand that no specific result is guaranteed. I further authorize the hospital staff to provide emergency
procedures deemed necessary by the veterinarian for the well-being of my companion animal.
Although we require pre-anesthetic blood screening for patients over six years of age, we strongly believe in its
benefit for all patients and encourage all clients to have this performed for their companion prior to anesthesia.
All patients will be placed on intravenous fluids while under anesthesia (except for very brief procedures,
including cat neuters). The cost is $46 which is included in our dog and cat spays and dog neuter packages.
Pre-anesthetic blood testing allows us to screen for underlying liver and kidney disease, diabetes,
anemia and dehydration in young apparently healthy patients.
The fee for pre-anesthetic blood screening is $48
( ) Please perform this service for my companion.
( ) Please do NOT perform this service for my companion.
( )This service was already performed on my companion.
A microchip is a form of identification that allows your companion to be identified even if his/her
collar is removed. We can quickly and painlessly insert a microchip under your animal’s skin while
he/she is under anesthesia.
The fee for microchipping is $51 (this fee includes a lifetime registration)
( ) Please perform this service for my companion.
( ) Please DO NOT perform this service for my companion.
I understand that all fees for my animal’s care will be due in full at the time of discharge. Please feel free to
request a written estimate. I understand if fleas are found on my companion, they will be treated at my expense.
I understand that it may be necessary for the veterinarian to contact me while my pet is under anesthesia. I will
be available at:
(PHONE NUMBER)________________________________.
If I am unavailable, please proceed in the best interest of my companion. I understand that there may be
additional charges.
Date________ Signature____________________________________________
When did your companion eat last?________
Northampton Veterinary Clinic is not a 24 hour medical facility. If your companion requires overnight hospitalization and you
would like him/her to receive 24 hour care we can transfer him/her to such a facility.