VETERINARY SURGICAL CONSENT FORM
EAST BAY VETERINARY CARE
286 MAPLE AVE. SUITE 4
BARRINGTON, RI 02806
Owner Name: ______________________________
Pet’s Name: ____________________ Species: __________
Breed: __________________________
Description
Colors: __________________________________________________
Markings: __________________________________________________
DOB: ______________ Age: ________ Sex: _______ Spay/Neutered: _______________
Home Phone: ________________________ Mobile Phone: _____________ (That you can be reached at today)
When did your pet last eat? (Date/Time)________ When did your pet last drink (Date/Time)___________
Is your pet on any medications/name?___________________
If so, last given?__________________
Does your pet have any chronic conditions?___________________________________________________
Anything else the Doctor needs to know?_____________________________________________________
An E-Collar will be provided to you at your expense in order to keep your pet from reopening the site.
All pets 12 weeks and older receiving services at our clinic must be accompanied by a current rabies certificate at
the time of surgery admission or a rabies vaccination will be given for an additional fee.
If your pet is found to have external parasites (fleas or worms) you will be financially responsible for the
treatment.
We offer and recommend the following services if not previously done for your pet:
Would you like to Microchip your pet during the procedure?
$30.00
⃣ No
⃣ Yes
Canine 4Dx Test for Heartworms and 3 Tick-Borne diseases (blood work)
$30.00
⃣ No
⃣ Yes
Feline Leukemia and Feline AIDS Test (blood work)
$30.00
⃣ No
⃣ Yes
I understand that by declining the recommended pre-operative blood work, my pet is at risk for complications
both during anesthesia/sedation and in the post-operative weeks to come.
Surgery Date: ______________________
Surgical Procedure:______________________________________________________________________
Vaccinations: (Circle the following that will be done today)
Canine: Rabies, Distemper DA2PP, Lyme, Bordetella (Kennel Cough),
Feline: Rabies, Distemper FVRCP, Leukemia
Canine Flu H3N8,
Leptospirosis
I understand anesthesia/sedation comes with inherent risks and that complications and even death are possible. I
understand that during the performance of procedures for the above situation(s), unforeseen conditions may be
revealed that necessitate extension of the foregoing procedures, or even procedures necessary and desirable in the
exercise of the veterinarian’s professional judgement. I have been advised of the nature of the services and
procedures as well as the risks involved and I also realize that results cannot be guaranteed. I additionally authorize
the use of appropriate anesthetics, and the administration of other medications, and understand that hospital staff
will be utilized as deemed necessary by the veterinarian.
_________________________________________
Owner Signature
____________________
Date