Surgical/Treatment Consent

Date:

Owner’s Name *

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Layout

Home Phone *

Cell Phone

Work Phone

PLEASE INDICATE IF ANY OF THE ABOVE INFORMATION HAS CHANGED SINCE YOUR LAST VISIT *

Yes
No

New Address

Address Line 1

Address Line 2

City

State

Zip Code

Layout

Pet’s Name *

Species *

Age *

Sex *

Breed *

Weight *

Surgical Procedures: (X all that apply) *

Other Surgical Procedure *

If your pet is here for a spay procedure, please complete the following:

Has this pet ever been used for breeding intentionally or unintentionally?

Yes
No

If this pet has been bred, how many litters have been produced?

Did the pet whelp naturally or via C-section?

Naturally
C-section

If pet has had a C-section, how many?

Treatment: (X all that apply) *

Other Treatment *

The Veterinarians at the Animal Medical Clinic recommend pre-anesthetic blood work for all patients undergoing anesthesia/ tranquilization. Pre-anesthetic blood work is required for all animals 8 years of age and older The blood work will assess for any contraindication to performing the procedure at this time; i.e. liver, kidney or other underlying dysfunction. The approximate cost for blood work can range from $50-$150. If blood work has been obtained within 30 days prior to the procedure and was within normal limits, the veterinarian may agree to waive pre-anesthetic blood work.

Choose One

I accept preanesthetic bloodwork
I decline preanesthetic bloodwork

Blood has been previously obtained within the last 30 days *

Layout

Describe Reason for Today’s Visit in as Much Detail as Possible:

Diet Information

Layout

Brand

How Much

Layout (copy)

How Often

When Did Patient Last Eat?

Nutritional Supplements (List)

Treats

Medication Information: (Please List)

Layout

Medication

Strength

How Often

Last Dose Given? (Date/time)

Layout

Medication

Strength

How Often

Last Dose Given? (Date/time)

Layout

Medication

Strength

How Often

Last Dose Given? (Date/time)

Layout

Medication

Strength

How Often

Last Dose Given? (Date/time)

Does your Pet have any Allergies (please describe) *

Is your Pet on Heartworm Prevention?

Yes
No

Year Round?

Yes
No

Brand

Do You Need Any Today?

Yes
No

Is your Pet on Flea/Tick Prevention?

Yes
No

Year Round?

Yes
No

Brand

Do You Need Any Today?

Yes
No

DOGS: Does your dog do any of the following: *

CATS: Is your cat

Indoor?
Outdoor?
Both?

Has your cat EVER been tested for Leukemia or Feline Aids?

Yes
No

When?

Has your pet exhibited any of the following symptoms?

Weight Loss - How long? *

Weight Gain - How long? *

Appetite Decrease - How long? *

Appetite Increase - How long? *

Increased Thirst - How long? *

Decreased Water Intake - How long? *

Vomiting - How Often? *

Diarrhea, Consistency - How Often? *

Coughing? - How long? *

Sneezing - How long? *

Wheezing - How long? *

Gagging/Choking - How long? *

Runny Nose - How long? *

Eye Discharge - How long? *

Difficulty getting up/Stiff - How long? *

Difficulty climbing stairs - How long? *

Incoordination - Describe *

Lameness/Limping - Describe *

Decreased Activity - Describe *

Listlessness - Describe *

Weakness - Describe *

Muscle Tremors - Describe *

Shaking (body) - Describe *

Seizures - Describe *

Head Tilt - Describe *

Shaking head - Describe *

Behavior Change - Describe *

Unusual Discharge - Describe *

Odor - Describe *

Scratching/Licking - Describe *

Poor Coat - Describe *

Hair loss - Describe *

Location(s)

Please describe any other problems or concerns

Walk-in/Drop Off (Admissions) may be required to leave a minimum 20% deposit of estimated costs of procedures. All remaining charges/balances shall be paid in full upon discharge from the hospital. WE DO NOT ACCEPT CHECKS. We do not bill.

**Large cash bills only accepted under certain circumstances. **

~WE ACCEPT CASH, DEBIT, CREDIT CARDS, VISA, MASTER CARD, AMERICAN EXPRESS, DISCOVER AND CARE CREDIT

If you do not currently have Care Credit and would like to apply. Please go to our website > Resources tab > Payment Options to apply

All reasonable precautions will be taken against injury, escape, or death of hospitalized patients. The Animal Medical Clinic, its staff and/or veterinarians, will not be held liable or responsible in any manner in connection there with as it is thoroughly understood that I assume all risks. I also understand that the Animal Medical Clinic is not staffed 24 hours a day and may warrant transfer to a 24-hour facility at the discretion of the veterinarian.

CONSENT FOR SURGERY/TREATMENT: I, being responsible for the above animal/animals, have the authority to grant the ANIMAL MEDICAL CLINIC my consent to receive, prescribe for, treat, and/or operate upon my pet. I understand that any quoted fees are “estimates” only and individual treatments and/or surgical procedures may require more time and/or surgical materials at additional costs. I understand and agree to the following surgery and or treatment plans and agree to pay all costs incurred for any and all professional services. I further understand that if further treatment is required, I will be contacted for verbal authorization of treatment and additional cost prior to administration of further treatment.

I hereby authorize ANIMAL MEDICAL CLINIC, it’s doctors and staff, to perform professional services as are in their opinion necessary and advisable for treatment and management of my pet’s health, medical problems and acknowledge authorization of all treatments (as deemed necessary by the veterinarian) to be performed as outlined and initialed by me on the Surgical/Treatment Consent Form. I further agree that an initial treatment plan has been explained and that further recommendations may be made pending diagnostic results which may incur further costs, for which I will be informed prior to undertaking of further treatment plans not already agreed upon. I understand that with either written and/or verbal authorization by telephone, that I am responsible for all charges incurred and that all services are to be paid at the time they are delivered or at discharge of my pet. I understand that a 20% deposit may be required upon admission with the remaining balance due upon discharge.

After reading the above, I have signed in agreement below

Authorization for professional services (must be over age 18):

Signed

Prepared By

Print Name

Date / Time

Date

Time

Please read the following surgical release form carefully. By signing at the end of this form, you are agreeing that you have read and understand the terms and conditions for your pet to be under the care of Animal Medical Clinic surgeons.

General Anesthetic Risks: Although every effort is made to ensure anesthesia is as safe as possible, there are inherent anesthetic risks to your pet. The incidence of complications from anesthesia are extremely low and we do not anticipate any in your pet, but, on rare occasions the following may occur:

1. Allergic reaction to the anesthetic agents.
2. Heart rhythm abnormalities.
3. Untoward reactions to gas anesthesia including drops in blood pressure or respiratory difficulties.
4. On very rare occasions, general anesthesia can result in death due to unforeseen cause.

Our trained veterinary medical team will take every precaution to take care of your pet while in our care. We monitor your pet’s vital signs diligently and utilize only the most up-to-date anesthetic agents and equipment.

Surgical Consent to Medical Treatment and CPR Directive: In the unlikely event that your pet will require resuscitative measures, please read the following directive, and choose one of the options for cardiopulmonary resuscitation (CPR).

During anesthesia, life threatening complications such as respiratory and/or cardiac arrest may occur, requiring medication treatment and/or CPR. If my pet stops breathing or his/her heart stops beating, I realize even the most successful CPR measures may not restore him/her to good mental and physical health.

No CPR procedures are to be administered.
CPR procedures are to be administered.

Endotracheal tube intubation (if not already utilized), positive pressure respiration, administration of emergency drugs, external cardiac massage (chest compressions)

I accept that if the Animal Medical Clinic surgical team are unable to reach me within twenty (20) minutes after the initiation of CPR and if after administering reasonable treatment there appears to be virtually no hope for medical success, CPR will be withdrawn.

Print Name

Date

Signature

Online Forms

Surgical Consent Form

Please fill out the form below, or if you prefer, please download the form, print it at home, and bring it in during your visit. Thank you

Surgical/Treatment Consent

If your pet is here for a spay procedure, please complete the following:

Diet Information

Medication Information: (Please List)

After reading the above, I have signed in agreement below

Authorization for professional services (must be over age 18):

Stay Up-To-Date

Pet Health Records & Appointments

Order Medications & Supplies Online

Shop Our Online Pharmacy

Ready To Visit!

Schedule An Appointment

Location

Contact Information

Hours

Have A Question?