Riverside Animal Hospital Anesthesia/Surgery Consent Form
Pet’s Name____________________________ Owner’s Name__________________________
Procedure(s):
 Juvenile Canine Spay (under 6 months and has not had 1st heat)
$125.00 or $3.10/lbs $__________
 Mature Canine Spay (over 6 months and/or has had heat or been pregnant)
$175-225 or $3.10/lbs plus $50-150 added $__________
 Feline Spay $105.00 (routine price applies unless currently pregnant)
 Canine Neuter $105.00 <40lbs or $2.60/lb >40lbs $___________
 Feline Neuter $75.00
 Feline Spay and declaw front feet $250.00
 Feline Neuter and declaw front feet $175.00
 Declaw front feet only $175.00 (if your cat is under 1yr he/she will stay 2 nights, if
your cat is over 1yr he/she will stay 3 nights)
 Declaw all 4 feet $250.00
 Dental Prophylaxis-(conditions in the mouth may necessitate extraction of teeth.)
Please ask for computer generated estimate
 Other procedures ________________________________ estimated $__________
Your pet’s health, safety, and comfort are very important to us at Riverside Animal Hospital. So that
we can help insure their health, all pets having surgery here must be examined by one of our doctors.
Several services that we provide to further enhance your pet’s safety and comfort are detailed below:
Pre-Anesthetic Blood Screening evaluates those organ systems most directly affecting the safety of
anesthesia (the liver and kidneys), and checks for anemia and dehydration, total protein and blood
glucose levels. This testing helps us plan the anesthetic procedures that are the best for your pet. We
can perform this screen on the same morning as surgery. (Fee $75.00)
For our geriatric patients (over 6 years of age), we recommend more intensive blood testing
which needs to be performed several days prior to an anesthetic/surgical appointment. This is a
comprehensive diagnostic health check which provides valuable information for both anesthetic safety
and future health care. (Fee is variable depending on the species and specific needs of the patient.)
Our feline patients also have specific testing available for contagious viral diseases. We can screen for
the feline leukemia virus (FeLV) and for exposure to the feline immunodeficiency virus (FIV). We
can perform this screen on the same morning as surgery. (Fee $50.00)
If the results of the blood testing are not in the normal range we will discuss our findings with you.
Sometimes we are able to adjust the medication and/or the procedure to make it safer for a pet with
specific needs. Occasionally we may need to postpone the surgery until a medical problem is
resolved.
For patients undergoing general anesthesia, we recommend intravenous (IV) fluids during the
procedure. An IV catheter and fluids help maintain blood pressure, oxygen perfusion, assist the body
in processing anesthetic medications more efficiently, and provide immediate access to the circulatory
system to give medications in the event of an emergency. (Fee $ 50.00)
We provide Pain Management medication with surgery. Our pets feel pain just as we do, even
though they may not show it on the outside. Your pet will receive an injectable pain medication at the
time of surgery that lasts up to 12 hours. We also have pain medication that can be given at home.
Please discuss this with your pet’s doctor at the time of check in.
We also recommend the ResQ ISO Microchip. This is an advanced pet identification and recovery
system. It is a service that can be done anytime. The pet does not need to be anesthetized, but an
elective anesthetic procedure is a convenient time to do this. We see the importance of identification
of lost or injured pets daily, so we take every opportunity to discuss this matter with our clients.
(Fee $50.00)
PLEASE CHECK THE SERVICE(S) YOU WOULD LIKE US TO PROVIDE:





Pre-Anesthetic Blood Screen
Complete Blood Profile
FeLV/FIV Test
ResQ ISO Microchip
Perioperative Fluids
 I prefer no pre-anesthetic testing be
performed at this time.
 I prefer no FeLV/FIV test at this time
 I prefer no microchip at this time.
 I prefer no fluids be given.
Advances in anesthesia and surgery have made routine procedures relatively safe with a low rate of
complications. Nevertheless, occasional problems can arise, due to pre-existing conditions not
evident during routine pre-anesthetic examinations. Riverside Animal Hospital will not be held liable or
responsible for complications resulting from anesthesia.
In the event of an emergency, I authorize Riverside Animal Hospital to perform any and all emergency
procedures that, in their opinion, are necessary for the well-being of my pet.
 Yes
 No
If your pet has an emergency we will contact you immediately.
In the event that my pet is not picked up within ten (10) days of the discharge date (unless
extended by a written agreement) ownership of said pet is vested to Riverside Animal Hospital.
I am responsible for the hospital bill to date of revocation of ownership.
I realize that my pet will be discharged only during regular office hours and when a doctor is
present. All fees for my pet’s care will be paid in full at the time of discharge. I realize
that, in many cases, it is impossible to determine in advance the extent of medical or surgical
treatment required, but a written estimate can be requested. It is understood if the estimate is
exceeded by more than 10%, I will be contacted.
I hereby authorize and direct Riverside Animal Hospital to perform the procedure(s) noted above
and to administer anesthetics or other drugs as deemed advisable for my pet. I understand the
procedure(s) and the relative risks involved.
Signature of owner/responsible agent: _____________________________date:____________
Phone number(s) where you will be reachable
the day your pet has surgery:
home #___________________________
cell #_____________________________
work #____________________________