Surgical Consent Form

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I recognize that, during the course of the operation, unforeseen conditions like being in heat, pregnant, cryptorchid (undescended testicles), pyometra (infection in uterus), cystic ovaries, etc, may necessitate additional or different procedures than those set forth above and there would be an additional charge. I further authorize and request that the above named surgeon and assistants perform such procedures as are in his/her professional judgment necessary and desirable. We are committed to keeping you informed during the process by contacting the emergency number provided below in case of any additional concerns. However, if we cannot reach you at the specified number, please understand that addressing the concern(s) during the operation may not be feasible. In the event of a serious, life-threatening medical condition and our inability to contact you, we reserve the right to administer treatment to your pet at our discretion, with any associated costs being your responsibility. I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me as to the results of the operation or procedure. I have been made aware of certain risks and consequences that are associated with the procedures described above.

All animals undergoing surgery will have an IV catheter placed. IV fluids help maintain proper blood pressure and flow as well as helping to protect the organs. In addition, we readily have a port available to administer potentially life-saving therapy.

Surgeries involve pain that often lingers over a few days. Pets can be stoic and sometimes they do not let us know that they are in pain. All animals will receive pain medications the day of the surgery. For dogs, take home medication will be dispensed.

All animals admitted must be current on their vaccinations.

By filling out this form, I hereby the Doctor and/or such assistants as selected by him/her, to perform a surgical procedure upon my pet.

DATE OF THE PROCEDURE *

YYYY

OWNER'S NAME AND LAST NAME *

HOME ADRESS *

EMAIL ADDRESS: *

PET'S NAME: *

SPECIES: *

CANINE

FELINE

OTHER

BREED: *

SEX *

MALE

FEMALE

NEUTERED

SPAYED

What procedure is being performed today?
*

Name of the Doctor performing this procedure *

Pre- Anesthetic Blood Work: A pet that appears healthy may still have hidden illnesses. Should a problem be found, anesthesia can be postponed or adjusted to fit your pet’s needs. Would you like us to run some blood work before surgery? The price is $88.00
*

Yes

E-Collar: Would you like us to put an Elizabethan collar to keep your pet from licking surgery site. It is between $12 - $26 for regular collars.
*

Yes

Microchip: Would you like us to implant a microchip on your pet while under anesthesia? Price will includes microchip, implantation, and registration. $70.00
*

Yes

Laser Therapy: Laser therapy is the use of an intense beam of laser light directed into tissues to reduce pain, increase blood flow, decrease inflammation and promote healing of the incision. $17.00
*

Yes

Histopathology: This is a test send to UGA to study the tissue removed to look for disease, like cancer. This is for tumor removal surgeries. The cost of this test is $139.00
*

Yes

N/A

Stone Analysis: This analysis will help our veterinarians determine what type of stone your pet may have. Would you like us to perform this test? The cost is $99.00? *

Yes

Would you like us to complimentary trim your pet's nails while under anesthesia? Free
*

Yes

For all procedures necessary to maintain oral health (extractions, bone replacement mixture, antibiotic gel, open root planning, etc.) that are discovered through dental examination and X-rays, I agree to one of the following:
*

Perform oral surgery at the doctor’s discretion to ensure a healthy mouth. I don’t need to be contacted first and I understand advanced dentistry can increase the total bill up to an additional $300-$600

You may perform oral surgery without contacting me but do not let my oral surgery bill exceed $700.00 without contacting me first.

Do not perform oral surgery without contacting me first. I understand you will make one attempt to contact me, and that my pet will be anesthetized when you call. If I don’t answer your call, my pet will be recovered from anesthesia without the needed treatment being performed, and that will result in my pet needing a separate procedure in the future

I am not doing a dental procedure today

Please list all medications your pet is on on the day of the procedure:
*

For the day of the procedure: Has your pet had any food or water in the last 8 hours? Please remember that we can't safely perform the surgery if your pet had food the day of the procedure.
*

YES

What is the best number we can reach you out today?

We are committed to keeping you informed during the process by contacting the emergency number provided below in case of any additional concerns. However, if we cannot reach you at the specified number, please understand that addressing the concern(s) during the operation may not be feasible. In the event of a serious, life-threatening medical condition and our inability to contact you, we reserve the right to administer treatment to your pet at our discretion, with any associated costs being your responsibility.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this consent form.
*

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