NEW HOPE ANIMAL HOSPITAL
Surgery Permission Form
___ Spay: Pregnant females or females in heat will have additional surgery charges due to increased surgery
time and surgical materials used.
_ Neuter: Cryptorchid males (pets that have one or no testicles descended) will have additional surgery
charges due to increased surgery time and surgical materials used.
_______ Declaw: A routine declaw is front feet only.
_ Mass removal: I approve histopathology. Yes ______ No _______
_______ Other:
*** I understand that in order for my pet to receive surgery, he/she must be current on his/her rabies and distemper
vaccinations; dogs must also be current on kennel cough (bordetella). If not current, they will be updated while your
pet is here. _____ (initial)
The requested procedure will result in post-operative pain, and so pain relief is recommended for all surgical
procedures. The cost of oral pain medication for the next 4 days is $15-$40 depending on the size of your pet.
Approve _____ Decline _____
Placement of an IV catheter is recommended prior to anesthesia. The IV catheter allows for fluid and medication
administration if needed. The cost of the IV catheter placement is $55.
Approve _____ Decline _____
An identification microchip can be implanted underneath the skin while your pet is under anesthesia. This microchip
will serve as identification if your pet is ever lost or stolen. The cost of microchipping is $48, which includes the
registration fee with homeagainid.com.
Approve _____ Decline _____
All surgical procedures require general anesthesia. A pre-anesthetic bloodwork panel to evaluate kidney and liver
function is recommended for all pets under 6 years of age. If abnormalities are detected, the doctor may recommend
further testing and/or postponing the surgery. The cost of this bloodwork is $58.
Approve _____ Decline _____
For pets older than 6 years, a full chemistry panel is recommended instead of the pre-anesthetic panel. The full
chemistry is more comprehensive than the pre-anesthetic panel. The full panel cost is $104 (instead of $58 for PAP).
Approve _____ Decline _____
All pets: I further understand that anesthesia and surgery, even when performed with extreme care, may result in rare
but unpredictable adverse reactions or complications. These reactions may include cardiac arrest, respiratory arrest
and death. _____ (initial)
Signed:
__________________Date: _________ Contact Phone:_____________