• Companion Animal Hospital Surgery / Dental Form

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Fasting for Surgery

  • DOG OWNERS

  • Current on vaccines? (Rabies, Distemper, bordetella)*
  • Heartworm test within last year?*
  • Need heartworm test today?*
  • Need fecal today?*
  • Need heartworm/flea prevention?*
  • Need Influenza vax?*

  • CAT OWNERS

  • Previously tested for FELV/FIV?*
  • Need FELV/FIV test today?*
  • Current on vaccines? (Rabies, Distemper)*
  • Need Leukemia vax?*

  • 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.*
  • Choose one:*
  • Consent for Extraction*

  • Microchip

    One time permanent ID $40.

  • I would like a microchip.*
  • 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.

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