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Surgery Consent Form
As the owner, or authorized agent of the above named animal, I hereby consent and authorize the clinic to receive, prescribe, treat, or operate on this animal. The nature of the procedures has been explained to me and no guarantee has been made as to the results or cure. I understand that the clinic staff & doctors will make every effort they possibly can to minimize the risk associated with general anesthesia & the services to be performed, but all risks will be assumed by me.
1. Rabies -
vaccination is required for pets 14 weeks and older.
2. Fasting -
I certify that the above animal has not been fed since last evening.
3. After hours care -
I understand that no one is on the premises after hours.
Adopted Rescue From Woof Gang Rescue Only
*
Your pet may be given both a pain & antibiotic slow release injection at the time of the procedure. These injections will last for 24 hours. The cost of these injections are not covered by the rescue.
Please administer these injections to my pet. ($85)
I decline these injections for my pet
Not adopted from Woof Gang Rescue / Does Not apply to my pet
Cat Surgery Only
*
Your pet may be sent home with a course of post-operative antibiotics. An extended-release antibiotic injection, Convenia, is available if you believe he/she would be difficult to orally medicate.
Please administer Convenia to my pet for post-operative antibiotic treatment ($45/cat)
I decline Convenia being administered to my pet
My pet is not a cat / Does not apply to my pet
Blood Work
*
Before putting your pet under anesthesia, we will perform a full physical examination. We highly recommend that a pre-anesthetic blood profile be performed to check the health of your pet's organs. At-risk medical conditions may not be detected without a pre-anesthetic blood profile.
Please Note: The pre-anesthetic panel is
MANDATORY
for pets ages 5 years and older as well as any pets that have a history of medical conditions or abnormal prior bloodwork.
I wish to have preoperative blood work performed on my pet. ($55)
I do not wish to have preoperative blood work performed on my pet.
IV Fluids
*
An intravenous catheter (IV), or SQ fluid therapy is recommended for anesthesia safety. An IV gives direct access to the veins in the event of a crisis. Fluid therapy / IV will maintain normal blood pressure, providing vital movement of blood to important organs such as the heart, brain, kidneys, liver and lungs. Please Note: IV Fluids is MANDATORY for pets ages 5 years and older.
I understand that my pet will receive fluid therapy and may have his/her leg shaved so that a catheter can be set. ($37)
I decline fluid therapy for my pet.
E-Collar
*
E-Collar - The use of an e-collar is HIGHLY recommended after surgery. E-collars help keep your pet from licking and chewing at the surgical incision site. In the event your pet removes their sutures and the incision opens, an additional charge would apply to repair the surgery site. You may choose to purchase an e-collar from us. Sizes vary as does cost ($14.00 - $20.00)
I would like to purchase an e-collar for my pet ($14.00 - $20.00)
I decline purchasing an e-collar at this time
CPR / DNR Permission
*
In the event my pet goes into cardiac/ respiratory arrest (heart stops/ stops breathing) I give permission for American Veterinary Hospital to perform CPR and other lifesaving measures. Costs of these services can run up to $250.00 and are not reflected in prior estimates.
Yes, I agree to CPR and other lifesaving measures. I understand that this may incur an additional fee and that there is no guarantee to the outcome of these measures.
No, I do not want my pet to be resuscitated in the event they go into cardiopulmonary arrest. Your pet will be assigned as DNR (do not resuscitate) and no lifesaving efforts will be made.
Consent
*
*I have read, fully understand, and agree to the above* I understand that all fees must be paid before my pet is released from the hospital. A written estimate of anticipated fees has been or will be provided for me upon request.
Pet's Name
*
Pet's Name at time of Adoption
(if adopted from Woof Gang Rescue)
Date of Scheduled Surgery Appointment
*
Date Format: MM slash DD slash YYYY
Signature
*
First
Last
Phone
*
Home
Client Center
New Clients
Office Tour
Kids Corner
Purina Diet Home Delivery
Online Pharmacy
Specials and Promotions
Testimonials
About Us
Our Hospital
Our Team
Policies, Procedures & Payment Options
My Pet
Pet Services
Boarding
Drop Off Services
In Home Pet Euthanasia
Pet Hospice Care
House Calls
Veterinary Emergency
All Services
Pet Health
Pet Health Resources
Interactive Animal
Breed Info
Videos
Pet Health Checker
News
Contact Us
Location / Hours
Make An Appointment
Gift Certificates
Pet Health Savings Plan
Affordable Vaccine Clinic
Affordable Vaccine Clinic
Packages & Additions
Clinic Dates
Payment Options
FAQs
Resources