Lake Country Veterinary Clinic, PLLC
Surgery Information
Has your pet eaten in the past 8 hours?
YES / NO
Has your pet had any illness (ie. coughing, sneezing, vomiting, diarrhea) in the past 7 days? YES / NO
If yes, please list: ____________________________________________________________________
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Does your pet have any history of seizures, liver or kidney disease, or heart condition? YES / NO
If yes, please list: _____________________________________________________________________
To your knowledge, has your pet had any previous anesthetic complications? YES / NO
If yes, please list:_____________________________________________________________________
___________________________________________________________________________________
Is your pet currently taking any medications? YES / NO
If yes, please list:_____________________________________________________________________
If your pet allergic to any medications/drugs? YES / NO
If yes, please list:_____________________________________________________________________
Has your pet recently shown any signs of exercise intolerance? YES / NO
Have your pets eating/drinking habits changed in the last 30 days? YES / NO
Has your pet experienced any trauma in the past 7 days? YES / NO
Has your pet experienced any major weight loss or gain recently? YES / NO
Is your dog current on heartworm prevention? YES / NO
Do you prefer medications in the form of liquids or pills when the option is available to you?
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Signature of Owner/Agent
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Date
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Lake Country Veterinary Clinic, PLLC
Surgery Consent Form
Patients name: ________________________
Phone number you can be reached at today:_________________________
As the owner or agent of the owner of the above animal, I hereby give my consent to Lake Country Veterinary
Clinic to perform the following procedures:
___________________________________________________________________________________________
_____________________________________________________________________________
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I have been advised of the nature of the procedure(s) involved. I understand, as with any procedure, that
there are possible complications to the aforementioned procedure(s). While Lake Country Veterinary Clinic will
do everything possible to avoid these, I’ve been made aware of the possible complications.
Should an emergency arise calling for procedures in addition to or different from those now
contemplated, I further request and authorize whatever emergency treatment is necessary. I agree to pay in
full for all services rendered, including those deemed necessary for medical or surgical complications or otherwise
unforeseen circumstances. When a dental is scheduled please be advised that extractions will be done when
deemed necessary for the comfort of the pet, and the owner will be responsible for all charges at the time
services are rendered.
Occasionally, sedation and/or anesthesia may become necessary for the comfort and safety of your pet.
While I understand that only safe and approved sedatives and anesthetics are used, I also understand that no
sedative or anesthetic is risk free. With that knowledge, I hereby authorize Lake Country Veterinary Clinic to
sedate or anesthetize the above mention animal if required. I also release the staff of Lake Country Veterinary
Clinic from any and all claims, except claims for negligence, arising out of or connected with the performance of
the requested care and/or treatment.
TO PREVENT THE SPREAD OF INFECTIOUS DISEASE AND PARASITES, ALL HOSPITALIZED,
BOARDED, AND GROOMING PETS MUST BE CURRENT ON ALL VACCINES AND FREE FROM
INTERNAL AND EXTERNAL PARASITES. VACCINES AND PARASITE CONTROL WILL BE
PROVIDED BY A VETERINARIAN AT OWNERS EXPENSE. ANY ANIMAL FOUND TO HAVE
FLEAS WILL BE TREATED AT THE OWNERS EXPENSE. ANIMALS MAY ALSO BE SHAVED TO
ALLOW US BETTER ACCESS TO A VEIN FOR BLOODWORK/IV CATHETER PLACEMENT.
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Signature of Owner/Agent
___________________
Date
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PLEASE REVIEW THE FOLLOWING OPTIONS RELATING TO ANESTHESA:
OPTION 1: PRE-ANESTHETIC PROFILE BLOOD SCREEN CONSENT/WAIVER
Like you, our greatest concern is the well being of your pet. A physical exam will be performed
prior to anesthetizing your pet. However, not all conditions (such as liver, kidney, metabolic) can be
identified on physical exam alone. For this reason, we strongly recommend pre-anesthetic screening in
order to identify any disorders prior to sedating your pet. Depending on the results, we may adjust the
dose or type of anesthetic used or advise in fluid therapy or delaying surgery. The cost of the preanesthetic profile is $48.
_____I Accept _____I Decline the recommended Pre-Anesthetic profile. I understand and assume all
responsibility for potential risks and complications during anesthesia from refusal to approve preanesthetic blood screening for my pets’ safety.
*Note: the Pre-Anesthetic profile will be performed on all pets 1 year of age or older who are undergoing general
anesthesia. The price of the profile will be added to the final invoice.
OPTION 2: INTRAVENOUS CATHETER CONSENT/WAIVER
Intravenous catheter placement allows for IV fluid administration during or after surgery, if
necessary, and to maintain optimal blood pressure. It also allows for the immediate administration of IV
emergency drugs and reversal agents should an anesthetic complication arise requiring their
administration. We highly recommend intravenous catheter placement in all anesthetic procedures. The
cost of intravenous catheter placement is $45 (without fluids) $58.15 (with fluids).
_____I Accept _____I Decline intravenous catheter placement.
*Note: Intravenous catheter placement will be performed prior to anesthesia in all pets 6 years of age or older. The
price of the catheter will be added to the final invoice.
OPTION 3: MICROCHIP IMPLANTATION REQUEST
An implanted microchip allows for fast identification and safe return of your pet in the
unforeseen instance that your pet becomes lost. While anesthesia is not required for microchip
implantation, it does provide an opportunity for a less painful and stress-free placement of the
microchip. The cost of the microchip implantation is $50, or $45 if performed with surgery.
_____ I would like Lake Country Veterinary Clinic to implant a microchip in my pet.
I understand that I am financially responsible for all charges incurred from medical treatment at
this facility. I also understand that all professional fees are due at time services are rendered.
We will gladly prepare a written estimate for you.
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Signature of Owner/Agent
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Witness
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Date