Companion Animal Hospital Surgery / Dental Form

Companion Animal Hospital Surgery / Dental Form
PET’S NAME: *
OWNER’S NAME *

First Name Last Name
Date *

Month Day Year
Date
DENTAL/SURGICAL/PROCEDURE: *
Fasting for Surgery
When did pet last eat? *
What meds is your pet taking? *
Last given? *
DOG OWNERS
Current on vaccines? (Rabies, Distemper, bordetella) *

Yes No N/A
Heartworm test within last year? *

Yes No N/A
Need heartworm test today? *

Yes No N/A
Need fecal today? *

Yes No N/A
Need heartworm/flea prevention? *

Yes No N/A
Need Influenza vax? *

Yes No N/A
CAT OWNERS
Previously tested for FELV/FIV? *

Yes No N/A
Need FELV/FIV test today? *

Yes No N/A
Current on vaccines? (Rabies, Distemper) *

Yes No N/A
Need Leukemia vax? *

Yes No N/A
Pre-Anesthetic Blood Screening
***(Required for pets 5 yr and older)***
Blood screens alert doctors to any potential health
problems while ensuring that your pet is healthy
enough for anesthesia/surgery.
I want a blood screen on my pet. *

Yes No
Choose one: *

Chem 10/cbc (5-7yr) $110 Chem 17/cbc (8yr & older) $117
Consent for Extraction *

Please do whatever is needed Please do whatever is needed up to amount authorized Please call me first for any additional treatment. Please do nothing more than I have authorized.
Microchip

One time permanent ID $40.
I would like a microchip. *

Yes No
Initials *
Authorization to Proceed.

I authorize the use of appropriate anesthesia/medications and support the personnel judgment of the Veterinarian. I understand even though every precaution is taken, anytime an animal is anesthetized there is a slight risk that an adverse reaction could potentially occur resulting in death.

2. I understand that during the above listed procedures an unforeseen medical condition may become evident that necessitates an extension of or an addition to these procedures. I authorize the performance of such procedures as are perceived necessary in the professional judgment of the Veterinarian.

3. I understand that the result of any procedures/operation cannot be guaranteed.
Initials *
I am aware of the risks and understand the information presented in this consent form, and I give the authorization to proceed with procedures/surgery and perform any and all life-saving procedures should the need arise.
Signature *

Clear
Phone Number *

Area Code Phone Number
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