Surgery Form 1 Consent - Rogue Equine & Companion Animal Clinic

Owners First and Last Names*

First Last

Pet's Name*

Age*

Sex*

Male
Male Neutered
Female
Female Spayed

Weight*

Date of most recent meal?*

Time of most recent meal?*

:

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

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 COMPLIMENTARY.

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 CONSENT

Information 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*

Signature*

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Phone

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Surgery Form 1 Consent Form