White House Animal Hospital
Consent Form for Surgery/ Treatment
Pet: _________________________
Owner: _________________________________________________
Address: ________________________________________________
Species: _____________________
Breed: _______________________
Color: _______________________
City, State, ZIP: __________________________________________
Home Phone: ___________________________________________
Birthdate: ____________________
Weight: ______________________
I am the owner or agent for the owner of the above named animal and
have the authority to execute this consent. I do
consent to and authorize the following procedure(s). ________________________________________________________________________
I authorize the use of appropriate anesthetics and other medications. I understand that the doctor will use pain medication, both in the hospital
and for follow up at home, as deemed medically necessary for my pet’s welfare. I authorize the use of pain medication for my pet both during
and after surgery. ________
I authorize the use of anesthetics but do not use pain relieving medication on my pet. ________
I understand that although all reasonable precautions and due care will be taken; there is always a potential risk with anesthesia and surgery. I
accept these risks and authorize White House Animal Hospital to perform such treatment as deemed necessary. I assume financial
responsibility for all charges incurred to patient, and if there is a financial limit, I have indicated that here. _________
I understand that there may be an additional charge if the pet is in heat, pregnant, or has excess fat or mature organs.
What you should know about anesthesia and your pet.
Because there is always the possibility that a physical exam alone will not identify all of your pet’s health problems, we strongly recommend that
a pre-anesthetic profile (a combination of tests) be performed prior to anesthesia. To ensure your pet can properly process and eliminate an
anesthetic, we run these tests to confirm that your pet’s organs are functioning properly, and to find hidden health conditions that could put your
pet at risk. The cost for this is $41.59 for blood chemistry or $71.24 for blood chemistry and a complete blood count.
Initial here to ACCEPT these tests _________
Initial here to DECLINE these tests_________
Please read and initial
Both hospital policy and state law require that pets be current on Rabies vaccinations. If you are unable to provide us with written proof, one
will be administered to your pet. The cost for this with a Wellness examination is $59.82 _________.
We strongly recommend that all dogs and cats also be current on other important vaccinations and tests, those are:
*Mandatory if more than 3 months overdue at the Veterinarian’s discretion.
Dogs
Cats
Rabies Vaccine
Accept______ Decline______
Rabies Vaccine
Accept_____ Decline _____
*Canine DA2LPPC (distemper, parvo)
Accept _____ Decline _____
*Feline Distemper
Accept _____ Decline _____
*Bordatella (kennel cough)
Accept _____ Decline _____
Feline Leukemia
Accept _____ Decline _____
Canine Influenza H3N8
Accept ______Decline _____
Fecal / Parasite Exam
Accept _____ Decline _____
*Fecal / Parasite Exam
Accept ______Decline _____
Heartworm Test
Accept _____ Decline _____
Please read and initial
If fleas are seen on your pet, he/she will have a flea product applied or given for the protection of all pets in the hospital. The cost for this
treatment ranges from $6.00- $25.00 (depending on size and product used) _________
Please read and initial
Payment is necessary before patients can be released from the hospital. I have read and understand this authorization and consent form.
_________
Owner/ Agent please sign: ________________________________________
Date: _____________
Preferred Contact method today 1. Phone __________________ 2. Text________________ 3. Email__________________________
Reminders for <animal>
<treatments>