Owner's Information

Name*

Pet's Information

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Please complete the following form allowing American Veterinary Hospital to perform a surgical procedure on your pet. We ask that you read the form in its entirety and acknowledge each statement. If you have questions or concerns regarding this form please contact our practice directly.

Rabies Vaccination - I understand a Rabies vaccination is required for pets 16 weeks and older.*
Fasting (withholding food) - I certify that the above animal has not been fed since last evening & fasting instructions were followed.*
After Hours Care - Pets are expected to be released at the end of the business day, however if the doctor deems necessary he may recommend the pet stays overnight for a quiet and secure recovery. I understand that no one is on the premises after hours.*
IV Catheter / Fluid Therapy - An intravenous catheter (IV) is placed giving direct access to the pet’s vein in the event of a crisis. Fluid therapy is also administered through the IV throughout the surgical procedure for anesthesia safety and maintaining a steady blood pressure. I understand my pet will be shaved where the IV is placed.*
Blood Work - A comprehensive blood work profile is required for every pet undergoing sedation, regardless of age.*
This profile was performed prior to your scheduled surgery date unless deemed by the doctor as an emergency.
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E-Collar (Cone) -.This collar helps keep your pet from licking and chewing at the incision site. Keeping an e-collar on your pet is HIGHLY recommended for the duration of recovery.*
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CPR / DNR Permission - Every effort is made by our practice to ensure the safety of the medical procedure when using sedation /anesthesia. I acknowledge there are always risks involved and the possibility of complications in any procedure*
CPR / DNR Permission*

WOOF GANG RESCUE ADOPTED PETS ONLY

Please read the options below. The rescue does not cover the cost of these options and you would be financially responsible at the time of discharge should you choose to opt-in.

E-Collar (Cone) - .This collar helps keep your pet from licking and chewing at the incision site. Keeping an e-collar on your pet is HIGHLY recommended for the duration of recovery.*
Pain Injection - This injection is given at the time of surgery and helps to make your pet comfortable while in Recovery and at home for the evening.*

As the owner, or authorized agent of the above named animal, I hereby consent and authorize American Veterinary Hospital to receive, prescribe, treat, and operate on my pet. The nature of the procedure(s) being performed has been explained to me and no guarantee has been made as to the results or cure. I understand that the practice staff and doctors will make every effort possible to minimize the risk associated with general anesthesia and the services to be performed, however all risks will be assumed by me.

- 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.
- I understand a written estimate of anticipated fees has been or will be provided for me upon request.

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This field is for validation purposes and should be left unchanged.