Borash Veterinary Clinic
79 Prospect Street
Peabody, MA 01960
(978) 531-8713
Surgical / Anesthesia Consent Form
Date ____/____/____
Client Name:_____________________
Address: ___________________
City, St Zip:_________________
Phone:_____________________
Patient: Name:____________________
Species:___________________
Breed:____________________
Age:______________________
Sex:_______________________
I hereby authorize and direct the Borash Veterinary Clinic to perform the following procedures on the abovementioned animal. I also authorize the use of appropriate anesthetics and other medications as deemed advisable for my
pet. I understand the nature of this procedure or operation and relative risks involved. I understand that the Borash
Veterinary Clinic will take all measures to ensure the well being of the above-mentioned animal. I authorize the Borash
Veterinary Clinic to provide any appropriate care should an unexpected complication occur. I realize results cannot be
guaranteed. I understand the related costs of the procedures and agree to full payment at the time of discharge. An
estimate can be provided if requested, and every attempt will be made to be as accurate as possible. If I neglect to pick up
the animal within five (5) days of written notice that it is ready for release and mailed to the above address, you may
assume the pet is abandoned. You are then authorized to dispose of as you see fit. Abandonment does not release me of
my obligation for payment of services rendered. I also understand that all unpaid balances are subject to a finance charge
of 1.5% per month or $5.00/ month, whichever is greater.
Procedure(s) to be performed: (check all that apply)
__ Spay (female)
__ Dewclaw Removal
__Tumor removal
__ Castration (male)
__ Laser Declaw
__ Vaccinations
__ Dental Work **
__ Ear Diagnostics/Treatment
__ Blood Work
__ Radiographs
__ Homeagain Microchip**
__ Other: _________
(While your pet is sedated we will also check nails / anal glands/ ears / & teeth)
I consent to the following…
__Yes – Laser Surgery (may not be optional)
__Yes – Pain management before & after procedure (may not be optional)
__Yes – Additional Pain Management (to take home- may not be optional)
__Yes – Will your pet need an e-collar to prevent licking?
__Yes – **Dental Extractions – Please proceed with extractions if needed
__Yes – **Dental Extractions – Please DO NOT proceed with extractions without contacting me
__Yes – ** I have been told about the Homeagain Microchip – a permanent pet identification chip that can help ID my pet
and get them home should they get lost – Do you wish to do this today? ___Yes / ___No
Does your pet have any of the following problems?
__ sneezing / __coughing / __vomiting / __diarrhea / __seizures / __changes in appetite or water consumption /
__changes in behavior – Please explain:_________________________________________________________
_________________________________________________________________________ _____/_____/_____
Signature of Owner/Responsible Agent
Date
Phone number where you can be reached during day of procedure:_______________________________________