Surgery Consent Form

Name *

First

Last

Email *

Primary Phone *

Secondary Phone

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? *

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

Has your pet ever had seizures? *

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

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

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 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.

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

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.

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 *

Date *

Name

Serving the pets of Katy, TX and beyond.

Get in touch!

Our mission is to provide an exceptional experience through compassionate service with a personal touch. We care for your four-legged family members as our own.

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Contact Us

Phone: 832-930-7857
Email: info@elysonvet.com

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Location

23015 FM 529 Road Suite 800

Katy, Texas 77493

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Hours

Mon, Tues, Thur, Fri: 8 am - 5:30 pm

Wed: 8 am - 1 pm

Sat: 8:30 am - 12 pm

(1st and 3rd Sat of each month)

Sun: Closed