Client Information

First Name*

Last Name*

Address*

Street Address

Address Line 2

City

State

ZIP Code

Phone*

Email*

Patient Information

Pet's Name*

Species*

Cat

Dog

Breed*

Sex*

Male

Neutered Male

Female

Spayed Female

Color*

Markings*

Age/DOB*

Your pet will be undergoing general anesthesia plus a surgical procedure today. In order to recognize any underlying abnormalities
your pet may have, we recommend having a pre-surgical blood profile run on your animal. This consists of a CBC, which will check
blood cells, and an ALT, ALKP, CREA, GLU, TP, and BUN, which will check blood glucose, kidney and liver enzymes.

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 before surgery. We highly recommend a blood profile for geriatric animals (animals older than 7 years).

There is an additional charge for these blood tests. We hope you understand the need for these important tests.

Do you wish to have the pre-surgical blood work run today for $138.40?*

I do

I do not

Has your pet eaten this morning?*

Yes

Is your pet allergic to any medications?*

Yes

If so, what?*

Would you like to have any additional procedure(s) done while your pet is under anesthesia? If so, what?*

Phone number where the owner can be reached*

Surgery to be performed*

I am the owner or agent for the above described animal and have the authority to execute this consent and authorization of the
above named surgery(s),

I understand that during the performance of the procedure(s), unforseen conditions may be revealed that necessitate an extension of
the foregoing procedure(s), or even different procedure(s), than those set forth previously. I hereby consent and authorize the
performance of such procedure(s) as necessary and desirable in the exercise of the veterinarian’s professional judgement. I have been
advised of the nature of the procedure(s), as well as the risks involved, and also realize that results cannot be guaranteed.

I additionally authorize the use of appropriate anesthesia, pathologist examination of excised tissue as deemed appropriate by the
veterinarian, and the administration of other rmedications, and understand that hospital staff will be utilized as deemed necessary by
the veterinarian. I have read and understand this authorization and consent.

Signature*

Date*

Name

This field is for validation purposes and should be left unchanged.

Surgery Consent Form

Client Information

Patient Information