Companion Animal Hospital Surgery / Dental Form

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

First NameLast Name
Date*

MonthDayYear
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)*

YesNoN/A
Heartworm test within last year?*

YesNoN/A
Need heartworm test today?*

YesNoN/A
Need fecal today?*

YesNoN/A
Need heartworm/flea prevention?*

YesNoN/A
Need Influenza vax?*

YesNoN/A
CAT OWNERS
Previously tested for FELV/FIV?*

YesNoN/A
Need FELV/FIV test today?*

YesNoN/A
Current on vaccines? (Rabies, Distemper)*

YesNoN/A
Need Leukemia vax?*

YesNoN/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.*

YesNo
Choose one:*

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

Please do whatever is neededPlease do whatever is needed up to amount authorizedPlease 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.*

YesNo
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 CodePhone Number
Should be Empty: