The Gwinnett Animal Clinic, PC
Owner’s Name: _______________________
Species: _____________ Breed:___________
Mass Removal Standard Consent Form
Name of Pet: ________________________
Sex: ___________ Age:____________________
I am the owner or agent for the owner of the animal described above and I have the authority to execute this
consent. I hereby consent and authorize the performance of the foregoing procedure(s) or operation(s):
I understand that during the performance of the foregoing procedure(s) or operation(s), unforeseen conditions or
problems may become evident that necessitate an extension of the foregoing procedure(s) or operation(s) than
those set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) or
operation(s) as are necessary in the exercise of the veterinarian’s professional judgement. I also authorize the
use of appropriate anesthetics and other medications and I understand that hospital personnel will be employed
as deemed appropriate by the veterinarian. I have been advised as to the nature of the procedure(s) or
operation(s) and the risks involved. I realize that results cannot be guaranteed.
_______ Food has been withheld since 9:00 PM last night and water has been withheld since 7:00 AM today.
_______ I understand that my pet may have his/her leg shaved so that a catheter can be set so that fluids may be
given during the anesthetic procedure. This keeps the blood pressure up and blood flowing to the vital organs,
replenishes fluids, and also provides an injection port for emergency drugs should they be needed.
_______For the safety of all our pets as well as our personnel, all pets must be current on rabies vaccinations
and dogs must be up to date on Bordatella (“kennel cough”) vaccinations. If they are not, these will be
administered while they are hospitalized.
To the best of your knowledge, has your pet ever had any seizures or convulsions? (circle one) YES NO
Other than flea and/or heartworm control, is your pet currently on any medication? (circle one) YES NO
Pre-Anesthetic Blood Testing Consent
Our greatest concern is the well being of your pet. A pre-anesthetic blood profile is needed to maximize the
patient safety and alert the doctor to the presence of dehydration, anemia, infection, diabetes and/or kidney or
liver disease that could complicate the procedure. The conditions may not be detected without a pre-anesthetic
profile. These tests are similar to those your own physician would likely run if you were to undergo anesthesia.
In addition, the results of these tests may be useful if your pet’s health changes, serving as a baseline for
comparison for future blood tests. The cost of the pre-anesthetic blood chemistry profile and complete blood
count is $70.
_______I accept the pre-anesthetic blood work recommended by veterinarian.
_______I decline the recommended pre-anesthetic blood work and request that you proceed with anesthesia. I
understand that there are always risks when using anesthesia or performing surgery on an animal.
Microchip Placement
We suggest that you consider protecting your emotional and economic investment. A very effective means of
increasing your chances of finding your pet should he/she ever become lost or stolen is by the implantation of a
HomeAgain microchip. Many animal control facilities, veterinarians, and humane societies have scanners
which could be used to identify your pet should he/she be taken to one of these facilities. Our staff can implant
one today if you desire. The cost for implantation is $39.99. This special program includes the initial set up
fee and the first year’s registration with HomeAgain. Future years’ registration will include an additional
fee beginning next year.
______I accept HomeAgain microchip implantation for permanent identification.
______I decline HomeAgain microchip implantation for permanent identification.
Submission of Tissues to Pathologist
Since by merely looking at a mass we cannot tell for certain whether a mass is cancerous, we suggest
that a pathologist evaluate practically all masses that we remove. The pathologist will usually take
extremely thin sections (usually only 1 or 2 cell layers thick) of the tissue and look at them under a
microscope. Based on the types of cells that are present, the pathologist can tell us such things as to
whether the mass is malignant, possible causes of the mass, if it appears that we left behind any
residual tissue that needs removal, what if any expected side effects may be associated with the
masses, and give us information as to whether further treatment is necessary.
There is an additional fee for submission of the mass(es) to a pathologist. The fee for the first mass is
$96.44 and $25.00 for each additional mass up to a total of 3 masses. An estimate can be prepared
for 4 or more masses.
_____I request that removed tissues be submitted to a pathologist for evaluation.
_____I request that tissues not be submitted to a pathologist for evaluation.
Signature of Owner/Agent__________________________________________Date__________________
Phone number(s) where you can reached today in case of emergency*:_____________________________
*PLEASE NOTE THAT IF MEDICAL DECISIONS NEED TO BE MADE FOR YOUR PET AND YOU
ARE UNAVAILABLE FOR CONTACT, THE DOCTOR WILL MAKE THE DECISION THAT HE OR SHE
FEELS IS IN THE BEST INTEREST OF THE PET WHICH MAY RESULT IN ADDITIONAL FEES.
massremovalconsentws.doc (7/09)