Town and Country Animal Hospital 1001 Schippel Drive Salina, KS 67401 (785)823-2217 www.tcvets.com
Date _____________ Owner’s Name ____________________________ Pet’s Name __________________________
Procedure: _______________________________________________________________________________________
Please review the following information carefully to ensure you understand our recommendations.
I have reviewed the information about pre-anesthetic blood work that has been provided and would like you
to perform the following recommended tests: Puppies <1 year of age (CBC), Adults 1-6 years of age (CBC & Pre-Surgical
Profile), Mature Adults >6 years of age (CBC, Chemistry Profile & Thyroid Test)
Complete Blood Count (CBC) ($33.57)
□ Recommended
□ Included
Pre-Surgical Profile ($55.30)
□ Recommended
w/CBC ($59.69)
□ Recommended
Chemistry Profile ($93.49)
□ Recommended
w/CBC ($100.86)
□ Recommended
Thyroid Test ($48.66)
□ Recommended
Heartworm +Wellness ($61.01)
□ Recommended
□ I accept the recommended blood work. □ I decline the recommended blood work.
Our Comfort Package is a wonderful way to help minimize the discomfort your pet will feel due to the
procedure. While undergoing and after surgery, your pet will receive a pain management injection.
Additional pain medication to go home will effectively control your pets discomfort during the recovery. Also
your pet will also receive a laser therapy treatment which uses a beam of laser light to penetrate tissue, which
leads to reduced pain, reduced inflammation and increased healing speed.
Comfort Package ($32.00)
□ I accept
□ I decline
We are pleased to offer laser surgery as an option for safe, comfortable treatment for your pet. There are
several benefits of laser surgery. Less Pain – the laser seals nerve endings as it “cuts”, so your pet may require
fewer anesthetics during the operation, also reducing pain after the surgery. Less Bleeding – the laser seals
small blood vessels during the surgery, greatly reducing blood loss. Less Swelling – the laser energy does not
crush, tear, or bruise the tissue because there is no physical contact with the tissue. This can reduce your pet’s
post-operative recovery time, leading to a quicker recovery and return to normal activities.
Surgical Laser ($41.00)
□ I accept
□ I decline
Heartworm disease develops when a dog is bitten by a mosquito carrying microscopic heartworm larvae.
Adult heartworms often cause lung disease and heart failure. A heartworm test, which is ran using a small
blood sample, is recommended yearly to ensure your pet is healthy and heartworm free. We also have a
Heartworm +Wellness blood profile that provides us with an abbreviated chemistry profile, as well as a
heartworm test. Heartworm testing is for dogs that are over the age of 6 months.
Heartworm test ($26.25) □ I accept □ I decline □ My dog has been tested within the last year.
Intestinal parasites, such as roundworms and hookworms are infectious to people. Often times it is difficult to
collect a fresh stool sample and bring it to our clinic. If your pet defecates while at the clinic, would you like us
to test it for parasites?
Fecal ($18.55) □ I accept
□ I decline
□ My pet has had a fecal test performed within the last year.
A microchip is the best form of identification because it is permanent. A microchip can be implanted at any
time. Home Again Microchip ($41.00)
□ I accept
□ I decline
□ My pet already has a microchip.
If needed, IV Catheter/Fluid Therapy will keep your pet hydrated during the procedure, and will compensate
for any blood loss. Fluids also help maintain adequate blood pressure, and the catheter gives us venous access
in case your pet should need any IV medications. Also it can be the difference between life and death in the
case of a complication. IV Catheter/Fluid Therapy ($67.00)
□ I accept
□ I decline
Canine Surgical Consent Form
Town and Country Animal Hospital 1001 Schippel Drive Salina, KS 67401 (785)823-2217 www.tcvets.com
Misc Services Available:
Pain Management Injection Only (Minimum $18.50) □ I accept
□ I decline
W/Mass Removal – Histopathology ($92.00) □ I accept
□ I decline
Pedicure □ I accept (Complimentary)
Ear Cleaning □ I accept ($12.00)
Vaccinations:
DHP/P-C is a five in one vaccine that includes protection against distemper, hepatitis, parvo, parainfluenza
and corona virus. Bordetella IN is a vaccine for kennel cough. Influenza is a vaccine for canine influenza.
Kennel cough and influenza are highly contagious viruses. These vaccines are recommended yearly and some
may require additional boosters to maintain a full year of protection. Rabies is given every two years after the
initial vaccine, which is only current for one year. In the state of Kansas the rabies vaccine is a legal
requirement. If you live within the city limits you are required to have a city license for your pet.
After reviewing the information please perform the following vaccines.
Rabies ($19.50) (REQUIRED VACCINE)
□ I accept
□ Current (Proof Required)
DHP/P-C ($40.70)
□ I accept
□ I decline
□ Current
Bordetella ($14.30)
□ I accept
□ I decline
□ Current
Influenza ($20.00)
□ I accept
□ I decline
□ Current
ALL ANIMALS ADMITTED MUST BE CURRENT ON THEIR RABIES VACCINE AND MUST BE FREE OF
EXTERNAL PARASITES. ANY ANIMAL FOUND TO HAVE FLEAS OR TICKS WILL BE TREATED AT THE
OWNER’S EXPENSE.
Your pet will be undergoing general anesthesia today. I understand that with any anesthesia and/or surgical
procedure there is a possibility of complications.
Signature _________________________________________________________ Date:
Phone # that you can be reached at? ________________________________________________________
Canine Surgical Consent Form