Client Information

Client Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Pet Information

Pet Name

Species

Breed

Sex

Male
Female
Undetermined

Surgery Details

Anesthetic and surgical procedure(s) to be performed *

What time did your pet last eat? *

Is your pet currently showing signs of illness? *

Yes
No

Does your pet have any known allergies?

Has your pet had any previous reactions to anesthesia? *

Yes
No
Not Sure

If your pet is a female, when was her last heat cycle?

Due to safety concerns, female dogs cannot be spayed within 8 weeks from the last day of their heat cycle.

Please list any and all medications your pet is currently taking and when they were last given:

If you are unable to give dental antibiotics the morning of the procedure, please bring them with you.

Pre-Anesthetic Laboratory Testing

A complete physical exam will be performed on your pet prior to the surgical procedure. However, this may not identify all systemic or metabolic problems. For this reason, we strongly recommend your pet have a pre-anesthetic blood panel to evaluate major organ functions prior to anesthesia.

Intravenous Catheter and Fluids

It is the policy of Pets and Vets as Partners, PLLC that all patients have an I.V. catheter placed during anesthesia. Any patient 7 years or older will have an I.V. catheter placed and be given intravenous fluids during anesthesia. It is at the veterinarian's discretion whether any other patient is administered intravenous fluids based on physical exam and pre-anesthetic lab work to guarantee patient safety. You are responsible for the additional charge.

Home Again Microchip

I would like to take this opportunity to have my pet microchipped at a discounted price of $50.00 rather than the regular price of $65.00. These prices include the one year online registration fee for your pet.

Vaccination Status

All admitted animals must be current on their vaccinations and must be free of external parasites. Any animal found to have fleas or ticks will be treated at the owner's expense. The bordetella (kennel cough) vaccine is also required for dogs. If a dog has not had this vaccine within the last year it will be given at the owner's expense.

Dental Procedures Only

Please select an option below

I will be available during the dental procedure and WOULD LIKE to be called if extractions are necessary. *If choosing this option, please make sure you are available, because we will be calling while your pet is under anesthesia and we will not be able to perform the extractions without your consent.
I will be available during the dental procedure, but I DO NOT need to be called if extractions are necessary.
I will NOT be available during the dental procedure and give my authorization to extract teeth as necessary.

If option one is selected above, please provide best phone number

Agreement *

Yes, I give my permission
No, I do not give my permission

I understand that some risks always exist with anesthesia and/ or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. I understand that the attending veterinarian will make every effort to contact me regarding treatment in the case of unforeseen emergencies. If unable to contact me, the staff may or may not have my permission to proceed with life-sustaining procedures.

Consent *

Yes, I agree to e-sign this document

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated for the safety or care of my pet. I hereby consent to and authorize the performance of such altered and/or additional procedures as deemed necessary in the veterinarian's professional judgment. I accept responsibility for any result in additional charges. I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow-up radiographs, re-check physical exams, and additional surgery due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions. I understand that payment is due at the time my pet is released from the hospital. I understand no staff will be attending to my pet overnight. Pets needing special care may be referred to a 24 hour hospital. I have read and fully understand the terms and conditions set forth above. I, the undersigned owner or agent of the pet identified above, authorize the staff of Pets and Vets as Partners to perform the above procedure(s).

Phone number at which the owner can be reached at today or tomorrow: *

Alternative Phone Number

Would you like to receive a text message with an update after your pet is awake from anesthesia? *

Yes
No

If yes, which phone number should we text?

Anesthesia/Surgical Consent