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* Male Male Neutered Female Female Spayed Weight* Date of most recent meal?* MM slash DD slash YYYY Time of most recent meal?* : Hours Minutes AM PM If surgery is for mass removal, do you elect for histopathology (biopsy)?* ACCEPT DECLINE NOT APPLICABLE Histopathology is to identify the tissue type and increase the chance of a positive diagnosis. This cost is additional.Is there any possibility of pregnancy?* NO YES UNKNOWN NOT APPLICABLE If presented for Spay and your pet is pregnant, do you 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. Any history of allergies to medication or issues with anesthesia?* NO YES UNKNOWN Any history of seizures?* NO YES UNKNOWN Does your pet have a known heart murmur?* NO YES UNKNOWN Is your pet on any medication?* NO YES, LISTED BELOW If your pet is on medication, please list ALL types and when last given.Do you want your pet to have post operative pain medication?* ACCEPT DECLINE Medication for post operative pain is highly recommended and is additional cost.Do you want testing for Heartworm Disease prior to surgery?* ACCEPT DECLINE Testing for Heartworm Disease is highly recommended and is additional cost. For cats only: Do you want testing for FeLV/FIV prior to surgery?* ACCEPT DECLINE NOT APPLICABLE Testing for FeLV/FIV is highly recommended and is additional cost. Would you like 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. E Collars are provided at additional cost.Do you want a nail trim for your 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 would like 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. 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* 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
