VISTA HILL’S ANIMAL HOSPITAL, LLC
398 South Emerson Avenue, Greenwood, IN 46143
Phone: 317-851-5000/Fax: 317-851-4164
Anesthesia/Procedure/Surgical Consent Form
Owner’s Name: _________________________________ Pet’s Name: ___________________
Veterinarian: _____________________________________________
Vaccinations Current: Yes_____ No_____
Required: Telephone number where you can be reached all day: ________________________
Canine/ Feline/ Exotic (circle one)
Breed:_____________________
Sex: Male/Female; Neutered/ Spayed (circle one)
Please answer the following questions:
Yes___ No___ Is your pet on heartworm prevention?
Yes___ No___ Any vomiting, coughing or diarrhea noted?
Yes___ No___ Has your pet had anything to eat or drink in the past 12 hours? If so, when? _____
Yes___ No___ Is your pet allergic to any medications? If so, what? _________________
Yes___ No___ Did your pet have a Pre-Op blood work prior to surgery ($65.00)? Declined ____
Yes___ No___ IV Fluid Support for patient safety ($49.97)?
Note: Any pet found to be carrying fleas and/or ticks will be treated at an additional expense
Procedure being performed today:
Spay ____
Neuter ____
Dental ____
Radiographs ____
Sedation ____
Hospitalization ____
Other _______________________
Also available at your request at additional charge:
Anal Glands ($21.95) ___
Clean Ears ($18.95) ___
Micro Chip ($35.00) ___
Nail Trim (NC, $16, $21)___ Other __________
Please initial one:
I agree to any necessary treatment even if it exceeds the estimate_________ (Do not exceed____)
*Please call before exceeding the high end of the estimate ____
*Please call before exceeding the low end of the estimate ____
*If I can’t be reached then the veterinarians/staff will finish the current procedure(s) at the next
available stopping point. Any additional procedures will have to be done at an additional time and
will be an additional expense. Understand this may put your pet(s) at additional risk.
I authorize the veterinarians/staff of Vista Hills Animal Hospital, LLC to administer
medications, anesthetics and perform the above procedures on my pet. I am also aware that
unforeseen events will not relieve me from any obligation to all reasonable costs incurred
regarding my pet(s).
I am the owner or agent for the above-described animal and have the authority to execute
this consent and authorization of the above named procedure(s).
I understand that during the performance of the procedure(s), unforeseen conditions may
be revealed that necessitate an extension of the foregoing procedure(s), or even different
procedures(s), than those set forth previously. I hereby consent and authorize the performance of
such procedures as necessary and desirable in the exercise of the veterinarian’s professional
judgment.
I have been advised of the nature of the procedure(s), as well as the risks involved, and
also realize that results cannot be guaranteed. The veterinarians/staff will use all reasonable
precautions and I agree not to hold the them or the hospital liable or responsible for occurrences
beyond their control.
I agree to allow my pet(s) previous records to be released.
I have read, understand and agree to this consent and all estimates.
Signature:_____________________________________ Date: ____________________