Berryville Avenue Veterinary Clinic
SURGERY CONSENT FORM
Patient’s Name:___________________Owner’s Name:__________________Date:___________
SURGICAL PROCEDURE
Describe:
______________________________________________________________________________
MEDICAL HISTORY
NOTE: If your pet is pregnant, obese, in heat or a giant breed, an extra fee will be
charged.
Please note any medical conditions: ________________________________________________________________
Current medications: ____________________________________________________________________________
Recent pregnancy/heat:________________Other______________________________________________________
Dogs- Current on heartworm preventive and immunizations (rabies, distemper, parvo, kennel
cough) ?
yes
no
If your dog does not take a heartworm preventative, or has not been tested in the last 30
days, he/she will need to be tested for heartworms prior to anesthesia.
Cats- Current on immunizations (distemper, rabies)?
yes
no
IF ANY FLEAS OR TICKS ARE FOUND ON ANIMAL(S) WE WILL DISPENSE AND
APPLY PREVENTITIVES.
SURGICAL OPTIONS
As with any surgery requiring general anesthesia, certain risks may result in serious complications or even death.
Every animal having surgery will have a CBC which checks for anemia, infection and platelets. An additional blood
screen will be performed to rule out pre-existing internal problems with the liver and kidney that may not be evident
upon physical examination, but could lead to serious complications with the anesthesia - this is included in the price
of surgery.
IV Catheter set-up
Microchip
Cost
$40.00
$45.00
Accept
Decline
All surgeries will require a pre-operative blood panel.
ANY ANIMAL THAT IS 5 YEARS OR OLDER OR NOT IN GOOD HEALTH WILL
REQUIRE HAVING A COMPREHENSIVE BLOOD SCREEN DONE, AND AN
I.V.CATHETER PLACEMENT TO HELP ENSURE THE SAFETY OF YOUR PET.
I am aware of the risk and understand the information presented in this surgery form and give Berryville Avenue
Veterinary Clinic and its staff members permission to proceed with the surgery and if the need arises, to perform
life-saving procedures and that I am liable for the extra cost involved, should my pet require this.
Client signature:_________________________________ Staff member signature:__________________________
Phone # I can be reached at today : _________________________________________________________