Surgery Consent Form

* Indicates required field

Owner Name *

First

Last

Phone Number *

Email *

Pet Name *

Species *

Breed *

Sex *

I authorize Barbara Sheffield, DVM and her agents, to receive and provide care for my pet listed above. I understand that all precautions will be taken to ensure the safety and good health of my pet during its stay and if any concurrent problems develop with my pet, treatment as deemed necessary by the doctor will be provided. I will assume full responsibility for the treatment expense involved.
To prevent contracting and the spread of infectious diseases and parasites, all animals received must be current on all vaccinations and free of internal and/or external parasites deemed necessary by the doctors at the Salem Veterinary Hospital. I authorize the doctor to provide vaccines and parasite control as needed for my pet.

Was your pet fasted overnight? *

Yes No

I have requested the following procedure for my pet: *

* Your pet will be undergoing sedation and/or general anesthesia plus a surgical or diagnostic procedure today. In order to recognize any underlying abnormalities your pet may have, we perform a pre-surgical blood profile on your animal. This consists of a PCV/TS, which will check blood volume, and an ALT, ALKP, CREA, GLU, TP, and BUN, which will check blood glucose, kidney function and liver values. A more comprehensive blood panel as well as other tests may be necessary if your pet is injured, ill, or older.
* These blood tests will help us to assess the health status of your pet more completely and determine if there are any additional precautions we need to take prior to surgery.
* I understand that all anesthesia involves some risk to my pet including (rarely) death and unforeseen complications such as infection, bleeding, or herniation with certain surgeries. I am aware that many, but not all, pre-existing conditions can be identified prior to surgery by performing these in-house tests.
*We recommend presurgical electrocardiograms to evaluate for possible heart anomalies that may not be discerned during auscultation alone. There is an additional charge for these tests.
Advanced Surgical Monitoring is required on all pets over 8 years of age.

I wish to have a pre-surgical EKG run today. (< 8yrs $22.80 Lead 2) (> 8yrs $37.60 3 leads) *

Yes No

I wish to have a Microchip placed today. ($38.00) *

Yes No

This question pertains to mass removals: *

I wish to have a biopsy performed on excised masses. I do not wish to have a biopsy performed on excised masses. Not applicable

I have read all of the above and understand and accept the risks involved. I also understand that payment is due at the time services are rendered.

Electronic Signature *

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Last

Please print out a copy of this form before clicking "submit", and be sure to bring the form with you to your scheduled appointment.

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