Surgical Consent Form

Rustic Line

Only the Best for Your Pets

Surgical Consent Form

We appreciate your trust in our pet care services. Kindly complete the online form or download and fill it out at your convenience before your visit. Bring the completed form with you for a smoother experience.
 

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Surgical Consent Form

There are always potential risks associated with anesthesia. If your pet is to be anesthetized, rest assured that advances in anesthesia and surgery have made routine procedures relatively safe with a very low rate of complications. Like you, our greatest concern is the well-being of your pet. Nevertheless, occasional problems can arise due to pre-existing conditions not evident during routine pre-anesthetic exams. To help reduce the occurrence of those problems, we recommend that all of these cases be screened prior to anesthesia by means of laboratory blood tests that check liver & kidney enzymes, glucose, as well as complete blood counts. The cost of these important tests is $77.00 for up to age 6; $86.00 for age 7 and older. Please understand, that even despite pre anesthetic screening, potential problems can still occur during anesthesia.

Would you like your pet to receive pre-anesthetic blood screening?

(THIS IS AN EXTRA FEE – SEE IN PARAGRAPH ABOVE) Even though our pet cannot effectively tell us if they are in pain, they do experience post-surgical discomfort the same as we do. We administer post-surgical pain medication for all surgeries.
Choose One**

Vaccinations

ALL ANIMALS ADMITTED MUST BE CURRENT ON THEIR VACCINATIONS AND MUST BE FREE OF EXTERNAL PARASITES. ANY ANIMAL FOUND TO HAVE FLEAS OR TICKS WILL BE TREATED AND VACCINATIONS WILL BE GIVEN AT THE OWNERS EXPENSE. The required vaccines include: DOGS: Bordetella (kennel cough) $22.00, DA2PLCPV $31.00 and Rabies Vaccine $13.00. CATS: Rabies Vaccine $13.00. FVRCP/Feline Leukemia Vaccination $39.00 is recommended for any cat that goes outdoors but is not required for surgical admission.

Additional Services

Please check any additional services (at additional cost) you would like your pet to have while under anesthesia:
Check additional services you'd like
(To be filled out by client)

Owner Information

(Please fill out completely) By signing below, I acknowledge that I have read and completely understand this anesthesia form, including the fees for extra services elected:
Your Name**
MM slash DD slash YYYY
I hereby acknowledge that Clinton Animal Hospital DOES NOT BILL for services. Payment is expected at time services are rendered. We accept Cash, Personal Check with driver’s license, American Express, Visa, Mastercard, Discover, and Care Credit. $25.00 charge for NSF checks. A deposit may be required for hospitalized pets.
Owners Signature**
This field is for validation purposes and should be left unchanged.