Surgery Form 1 Consent - Addendum Form This form is an addendum to the Surgery 1 Consent Form. The Surgery 1 Consent form must be completed first. Owners First and Last Names* First Last Pet's Name* Mass removal and election for histopathology (biopsy): I have changed my mind and DO WANT histopathology performed.* ACCEPT DECLINE NOT APPLICABLE Histopathology is to identify the tissue type and increase the chance of a positive diagnosis. This cost is additional.I have changed my mind - If presented for Spay and your pet is pregnant, I DO WANT TO PROCEED with the procedure as scheduled.* ACCEPT DECLINE NOT APPLICABLE Prior to surgery, an effort is made to externally palpate for a normal abdomen and uterus. If there is any indication of possible abnormality or pregnancy, this predetermination will give us direction on how to proceed. I have changed my mind - I DO WANT my pet to have post operative pain medication.* ACCEPT DECLINE Medication for post operative pain is highly recommended and is additional cost.I have changed my mind - I DO WANT testing for Heartworm Disease prior to surgery.* ACCEPT DECLINE Testing for Heartworm Disease is highly recommended and is additional cost. For cats only: I have changed my mind - I DO WANT testing for FeLV/FIV prior to surgery.* ACCEPT DECLINE NOT APPLICABLE Testing for FeLV/FIV is highly recommended and is additional cost. I have changed my mind - I DO WANT an E Collar for post operative care.* ACCEPT DECLINE NOT APPLICABLE E Collars are highly recommended to prevent licking or chewing on surgery sites/sutures. I have changed my mind - I DO WANT a nail trim for my pet while under sedation/anesthesia.* ACCEPT DECLINE Nail trims under sedation/anesthesia is at reduced stress for many animals. This is with additional cost. I have changed my mind - I DO WANT a microchip placed while my pet is sedated or under anesthesia.* ACCEPT DECLINE Microchips are the number one method of pet identification should you become separated. The microchip number is automatically entered in a national database and is a standard for identification. Accuracy and Agreement/Consent* I AGREE AND CONSENTInformation provided is accurate to the best of my knowledge and I understand there are additional charges for services selected above. Where a service has been declined, I understand those services will not be performed. Date of agreement and consent* MM slash DD slash YYYY Signature*Sign with finger if mobile phone or tablet, drag mouse if PC or Mac. CAPTCHANameThis field is for validation purposes and should be left unchanged. Δ
