Surgical Consent Form

Client Name

First

Last

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Phone Number

Patient Name

Species

Breed

Sex

Male

Female

Color

Weight

Surgery Information

Anesthetic and surgical procedure(s) to be performed:

If your pet is having a mass removal, would you like a histopathology?

Yes

Doctor performing procedure(s):

Pamela Fornwalt DVM

Kris Gresham DVM

Brittany Haggard DVM

Ricky Poe DVM

Ken Wegenhart DVM

No Preference

I, the undersigned owner or agent of the pet identified above, authorize the staff of East Paulding Animal Hospital to perform the above procedure(s).

I understand that some risks always exist with anesthesia and/ or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated.

In order to offer the best medical care possible, we recommend a pre-anesthetic blood screen for your pet undergoing an anesthetic procedure. ANESTHESIA CARRIES SOME RISK (even though it may be small). The bloodwork consists of two parts, a CBC – which can identify anemia, infection and clotting disorders. The second is a chemistry, which assesses the liver and kidney functions and many other metabolic diseases that may need to be addressed before surgery.

Fee for blood screen is $135.00

Yes, I give my permission

No, I do not give my permission

Fee for initial application of Oravet + 8 week home supply is $75.00

Yes, I give my permission

No, I do not give my permission

Fee for Microchip (Datamars – cost of chip and lifetime registration) – $60.00

Yes, I give my permission

No, I do not give my permission

Post-Operative pain management, please select the appropriate box for your pet's needs.

My pet will need to be provided with pain medication for post-operative recovery

I have provided pain medication to be given to my pet for post-operative recovery.

List medication, strength, and dosage

We require all pets who undergo surgery in our hospital to wear an Elizabethan Collar during their recovery from surgery.

My pet needs to be sent home with an Elizabethan Collar to wear after surgery.

I have brought my own Elizabethan Collar for my pet to wear after surgery.

Consent

I understand that any retained deciduous or infected teeth will be pulled during surgery at my expense.

• If any extensive dirt or external parasite problem is found on my pet, I understand that the patient will be cleaned
and/or deflead at my cost.

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I
understand that no guarantee or warranty has been made regarding the results that may be achieved.

I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as
follow up radiographs, re-check physical exams and additional surgery due to post-op complications. These are more likely to
occur when there is a failure to comply with the aftercare instructions.
I have read and fully understand the terms and conditions set forth above.

Signature(Required)

Date(Required)

MM slash DD slash YYYY

CAPTCHA

This field is for validation purposes and should be left unchanged.