Name *

First

Last

Primary Phone *

Secondary Phone

Email *

Pet's Name *

Surgical Procedure *

Additional Surgical Procedure *

Please select N/A if your pet is only having one procedure performed.

General Patient Information

Did your pet eat this morning? *

Yes
No

Has your pet had any vomiting, diarrhea or coughing within the last 10 days? *

Yes
No

If yes, please explain *

Has your pet ever had seizures? *

Yes
No

If yes, please explain *

Is your pet allergic to any medications, anesthetics or vaccines? *

Yes
No

If yes, please explain *

Is your pet presently on medication(s) including aspirin? *

Yes
No

If yes, please list all medications *

Please be aware: if fleas or ticks are found on your pet while in the clinic, they will be treated at an additional cost to you.

Owner Responsibility

I understand that home care administered by myself or a designated caretaker may be required to achieve the best overall success. *

I have read and understand

I agree to make myself available by telephone during the approximate time interval of 8:30 am to 2:00 pm. *

I have read and understand

I agree to pay today, in full for services rendered, including those deemed necessary for medical or surgical complications or unforeseen circumstances. Furthermore, I understand that regardless of the outcome of the procedures I am responsible for payment of the procedures immediately. *

I have read and understand

Hospital and Procedural Information

Anesthesia: Pre-surgical blood tests and physical exam will enable us to assess and minimize the risk of anesthesia to your pet.

Monitoring: To minimize anesthesia risk, we monitor the heart, blood pressure, respiration rates, temperature, and oxygenation.

Catheterization: For sterility, hair will be shaved over a vein on the leg so that an intravenous catheter (I.V.) can be placed. Blood pressure may lower during anesthetic procedures and fluid therapy aids in supporting your pet’s internal organ systems. It also allows immediate access to the vascular system in case of an emergency.

Pain Management may be necessary for some dental procedures. The doctor will administer pain medications according to your pet’s needs, which can be an additional fee ranging from $20.00 to $50.00.

Antibiotics are an additional fee ranging from $20.00 to $75.00 and may be prescribed by Dr. Smith for your pet’s oral hygiene needs.

Pre-Op Bloodwork: Blood work is required for any patient going under anesthesia to ensure that kidney and liver function is adequate to process and eliminate anesthesia.

Please note: Additional surgical options will require an addition consent form to be signed.

As the owner/agent; I hereby consent and authorize the performance of the following procedures/treatments.

Pre-surgical blood work: labwork is required; will be performed the day of the procedure if not completed at a prior appointment. Additional $40
Microchip: $48.00 We offer Microfindr to all our clients. Microchips are designed to help identify lost pets and reunite them with their owners. One in three pets are lost during its lifetime, and only one in ten lost pets is found.
Dremel nail trim ($18)
Ear cleaning ($15.50)
Anal gland expression ($19)
Ear hair removal ($19.50)
Courtesy nail trim

Surgical Extractions

It can be difficult to predict if teeth need extraction when an animal is awake because tartar and movement interfere with the assessment. Severely diseased teeth can cause considerable pain and discomfort and are a source of infection for other organ systems (liver, kidney, lungs, and heart). During the dental cleaning, the teeth are evaluated, and if found to be diseased they may require extraction. The cost of extractions varies depending on the amount of time taken and the difficulty of the extraction and can range from $30.00 to $90 per tooth.

Once Dr. Bethany Smith has reviewed the dental radiographs and completed the oral assessment, you will be contacted at the provided number(s) regarding additional recommendations. Dr. Smith will review additional costs for recommended procedures/surgical extractions with you and request consent. If you are not reached within 15 minutes, Dr. Smith will complete the previously agreed upon care plan and begin recovery.

Please be aware that if you decline any needed procedures at this time or are not able to be reached, it may mean your pet will need second anesthesia at another time in order for those procedures to be performed.

CPR

In the event that your pet should experience cardiac or respiratory arrest while being hospitalized today, do you give consent for resuscitation efforts to be initiated until you can be contacted further and notified of their status? By consenting to this service, you are also acknowledging that certain fees will apply. If you are not able to be contacted immediately, resuscitation efforts will be continued to be performed at the doctor’s discretion. Please select your choice below. *

I agree to CPR being performed in case of arrest
I elect a “Do Not Resuscitate” status in case of arrest

Authorization

I have read and fully understand this anesthesia and surgery consent form.

I have been advised as to the nature of the procedure(s) and the risks involved. I realize that the results cannot be guaranteed. I am aware that THERE ARE RISKS WITH ANY ANIMAL GOING UNDER ANESTHESIA and know that the veterinarian will take all necessary precautions and I am encouraged to discuss any concerns I have about those risks with the hospital’s medical staff before the procedure(s) is/are initiated. *

I have read and understand

While Elyson Animal Hospital provides the highest quality of anesthesia monitoring, surgical services, and dentistry, I completely understand the possibility of unforeseen complications that may occur during any associated anesthetic, surgical procedure, or dentistry. I fully acknowledge and understand these medical risks. I recognize that the veterinarian and hospital staff will do all that is necessary to minimize such risks. I will hold harmless Elyson Animal Hospital, the veterinarian, or any hospital staff member liable for any complications that may or should arise in my pet’s medical treatment and care. *

I have read and understand

I understand that during the performance of the procedures/treatments, unforeseen conditions or problems may be revealed that necessitates an extension of the procedure(s) or that different procedures than those set forth above may become necessary. Therefore, I consent to and authorize the performance of any such procedure(s) the veterinarian deems necessary. The staff of Elyson Animal Hospital will contact me as soon as medically able to inform me of any changes in my pet's condition. *

I have read and understand

I also authorize the use of appropriate anesthetics and other medications, and I understand the hospital support personnel will be employed as deemed necessary by the veterinarian. *

I have read and understand

I understand that the hospital is not liable for any lost or damaged personal property (leashes, collars, etc) that are left in the hospital. *

I have read and understand

If I neglect to pick up my pet within 5 days of the date below and do not notify Elyson Animal Hospital within that time frame, Elyson Animal Hospital may assume that my pet is abandoned. *

I have read and understand

No warranty or guarantee has been offered or given to me as to the results or cure afforded by these treatments or procedures. *

I have read and understand

I AM AT LEAST 18 YEARS OF AGE. I have read and understand this authorization and have the authority to execute this consent. *

I have read and understand

Signature *

Clear Signature

Date *

General Patient Information

Owner Responsibility

Hospital and Procedural Information

Surgical Extractions

CPR

Authorization

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