Surgery Form 1 Consent Form Prior to acceptance for a scheduled procedure, answers to the following questions are important to ensure the safety of your animal and appropriate services are rendered. Owners First and Last Names* First Last Pet's Name*Age*Sex*MaleMale NeuteredFemaleFemale SpayedWeight*Date of most recent meal?* Date Format: MM slash DD slash YYYY Time of most recent meal?* : HH MM AM PM If surgery is for mass removal, do you elect for histopathology (biopsy)?*ACCEPTDECLINENOT APPLICABLEHistopathology is to identify the tissue type and increase the chance of a positive diagnosis. This cost is additional.Is there any possibility of pregnancy?*NOYESUNKNOWNNOT APPLICABLEIf presented for Spay and your pet is pregnant, do you want to proceed with the procedure as scheduled?*ACCEPTDECLINENOT APPLICABLEPrior 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. Any history of allergies to medication or issues with anesthesia?*NOYESUNKNOWNAny history of seizures?*NOYESUNKNOWNDoes your pet have a known heart murmur?*NOYESUNKNOWNIs your pet on any medication?*NOYES, LISTED BELOWIf your pet is on medication, please list ALL types and when last given.Do you want your pet to have post operative pain medication?*ACCEPTDECLINEMedication for post operative pain is highly recommended and is additional cost.Do you want testing for Heartworm Disease prior to surgery?*ACCEPTDECLINETesting for Heartworm Disease is highly recommended and is additional cost. For cats only: Do you want testing for FeLV/FIV prior to surgery?*ACCEPTDECLINENOT APPLICABLETesting for FeLV/FIV is highly recommended and is additional cost. Would you like an E Collar for post operative care?*ACCEPTDECLINENOT APPLICABLEE Collars are highly recommended to prevent licking or chewing on surgery sites/sutures. E Collars are provided at additional cost.Do you want a nail trim for your pet while under sedation/anesthesia.*ACCEPTDECLINENail trims under sedation/anesthesia is at reduced stress for many animals. This is with additional cost. I would like a microchip placed while my pet is sedated or under anesthesia.*ACCEPTDECLINEMicrochips 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. This service is at additional cost.Comments or special requests?Please note here if you have any comments or special requests.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* Date Format: 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.
