Procedure ConsentClient Name First Last Patient Name First Last Account NumberDate MM slash DD slash YYYY SpeciesBreedSexAgeColorI, the undersigned, do hereby certify that I am the owner (duly authorized agent for the owner) of the animal described above, that I do hereby give Jackson Hwy Vet Clinic agents, servants, and/or representatives full and complete authority to perform the surgical procedure as described and to perform any other procedure that, at her discretion may be useful to promote the health of the above-described pet, and I do hereby and by the present forever release the said doctor, her agents, servants, or representatives from any and all liability arising from said surgery on said animal.In Heat/Pregnant? Yes NoIf pregnant, continue w/ spay? Yes NoBoth testicles present? Yes NoHistory of seizures?(Required) Yes NoWhen was the last seizure?(Required)If having a dental procedure today, are dental extractions ok? Yes NoFIV/FELV Combo Test? Recommended (For Cats Only) Yes NoPre-Anesthetic Bloodwork – $130 – (Recommended for patients over 5yrs) Yes NoEvery surgical or anesthetic procedure has risks involved. Therefore, we always recommend pre-anesthetic bloodwork for each patient. If there are any abnormalities noted prior to the anesthesia being administered, appropriate steps can be taken to ensure the safety of your pet.Post Operative Pain Care – $30 – $100 Yes NoAny surgical procedure carries with it the unfortunate side effect of post-operative discomfort. In order to minimize your pet’s discomfort, we offer post-operative pain management that includes take home pain medication to help with the healing process and decrease inflammation.IV Fluids, Fluid Pump – $119.50 – (Recommended . for spays over 1 yr. or if patient has had litters previously) Yes NoDuring any surgical or anesthetic procedure, we recommend the placement of an intravenous catheter and fluid administration. Benefits of IV catheter placement and fluids include, but are not limited to: continued hydration for the pet and their internal organs, and guaranteed access to administer life saving medications in the event of an anesthetic emergency.Sedation – $25 – $60 Yes NoIf you feel your pet will be active when at home, sedatives are primarily for canines but are available for felines if needed. It helps the healing process if your pet stays calm during the 10-14 days post-surgery. No running or jumping during this time.Microchip – $64.50 Yes NoIn the event that your pet is lost or stolen, the HomeAgain microchip can be used to help reunite them with you as it has a unique identification number that can be traced back to you if they are found and scanned by a veterinarian or animal control facility.Elizabethan Collar (Price depends on size) – $9-$16 Yes NoPrevents your pet from licking or chewing at their surgical site or pawing at their face after any dental extractions.WE REQUIRE THAT ALL DOGS AND CATS BE CURRENT ON RABIES BEFORE ADMISSION TO THE HOSPITAL. IF THIS VACCINATION IS NOT CURRENT IT WILL BE ADMINISTERED AT THE TIME OF ADMISSION TO THE HOSPITAL AT THE OWNER’S EXPENSE.Rabies Vaccine – $22 – Required (Please provide rabies certificate if vaccine was given by another clinic) Yes CurrentDewormer Yes NoVaccines Yes No CurrentVaccines ListDid you withhold your pet’s food the day of surgery? (Please remember to remove all food after 10pm the night before procedure) Yes NoIf an animal is infested with fleas/ticks he/she will be treated at the owner’s expense.Emergency Authorization CPR DNRAnesthesia and surgery have made routine procedures relatively safe, with a low rate of complications. Nevertheless, occasional problems can arise due to pre-existing conditions not evident during routine pre-anesthetic examinations. Jackson Hwy Vet Clinic will not be held liable or responsible for complications resulting from anesthesia. In the event of an emergency, I may or may not give my consent to Jackson Hwy Vet Clinic to perform any and all emergency procedures that in their opinion are necessary for the well being of my pet.FREE ADDITIONAL TREATMENTS FOR SURGERIESCapstar (24hr flea control for your pets comfort and protection from fleas) Yes NoCourtesy Nail Trim Yes NoPrimary Contact NamePrimary PhoneSecondary Contact NameSecondary PhoneSignatureDate MM slash DD slash YYYY Employee Initials:As an additional measure for tactical post-surgical healing, we are implementing laser healing therapy and now incorporating Phovia light therapy to streamline the healing process and reduce post-surgical complications. If you do not wish to receive this therapy, please inform the surgical staff.(Required) I understand the above.CAPTCHAΔ
