Gibson Animal Clinic Surgical Consent Form
Owner Name: _____________________ Pet Name: ___________________
Age: __________ Sex: ____________
Surgical Procedure: _____________________
Phone Number (to reach you today if needed): ________________________
My Pet:
Has not eaten since 10pm the night before surgery
No
□
Yes
□
Is currently on a flea/tick preventative (pet will have to be free of external parasites
prior to surgery)
No □
Yes □
Is current on vaccines (vaccines must be current prior to surgery)
No □
Yes □
Has current (negative) test for heartworm or feline leukemia
No □
Yes □
If not would you like them to be tested today? No
□
Yes
□
Has your pet ever had problems with surgery/anesthesia in the past?
No □
Yes: ______________________
To decrease the risk of complications occurring, we recommend pre-anesthetic blood
work. The cost for this is $80. Would you like to add this service?
No □
Yes □
Having intravenous (IV) access can be life saving if anything should need to be given
IV during surgery. It also eases administration of anesthetics and only costs $40.
Would you like your pet to have an IV catheter placed?
No □
Yes □
An Elizabethan collar is available in order to keep your pet from reopening the
surgical site. Would you like to add it to the cost? (Prices for collars vary)
No □
Yes □
Would you like the doctor to microchip your pet ($37) during the procedure?
No □
Yes □
I understand that anesthesia involves some risk to my pet. I will discuss any questions or
concerns that I have with my veterinarian before the procedure. I grant my consent for this
procedure and agree to pay in full for the services rendered.
_________________________________
Signature
_________________
Date