Surgery Consent | My Hope Animal Clinic

Please read carefully and sign

Date

Owner's Name(Required)

Pet's Name(Required)

CHART #

Breed(Required)

Sex(Required)

Age(Required)

Color

Phone I can be reached on at all times today(Required)

Evening Phone

All animals must be current on all vaccinations and free of external parasites (Fleas and/or ticks) prior to surgery.
Vaccinations and/or parasite treatment will be given at owner's expense.

As the owner or owner's agent of this animal, I hereby give my consent to update this pet with any required vaccinations, to include Rabies, DHPPLA(canine), FVRCP(feline), Bordatella, and Canine Influenza(Required)

I consent for my pet to have the following procedure(s). Initial below.(Required)

List procedure(s) to be done.(Required)

Date of procedure(s)(Required)

(Additional fees for Pregnant / In-Heat Spay or Obese plus cost of antibiotics: K-9 $72 & Feline $39.00)
(Additional fee for crypt orchid inguinal/abdominal plus cost of antibiotics: inguinal $75.00, abdominal $150)

I, being responsible for the above pet, have the authority to grant you consent to receive, prescribe for, treat and/or operate on this pet. I understand that the doctor and staff will use all reasonable precaution against injury, escape and the death of my pet. I understand that all anesthesia involves some minimal risk to my pet and I will not hold you liable or responsible in any manner whatsoever or under any circumstances in connection therewith as it is thoroughly understood that I assume all risks. I accept full financial responsibility for my pet. I am also aware that unforeseen events resulting from the procedure(s) will not relieve me from any obligation for all reasonable costs incurred regarding this animal.

I understand and agree that Hope Animal Clinic is NOT responsible for any expenses I incur if I do not follow their post-operative surgical recommendations.

Signature of Owner/Agent(Required)

Before putting (animal) under anesthesia, the veterinarian will perform a physical exam to identify any existing medical conditions that could complicate the procedure or compromise the health of your pet. Because the possibility exists that a physical exam alone will not identify all of (his) health problems, we strongly recommend that a surgical blood profile be performed. The fee is $92.00. This bloodwork can lead to early diagnosis of various health issues. Bloodwork and an IV Catheter are REQUIRED on any pet over 7 years of age. We also reserve the right to place and charge for a catheter on any pet if medically necessary. ($17.50)

Consent to Blood Testing(Required)

Please COMPLETE the recommended blood testing prior to administering anesthesia to my pet.

I DECLINE the recommended blood testing at this time and request that you proceed with anesthesia. I understand that my pet’s health could be at risk if a medical condition goes undetected when my pet is placed under anesthesia.

Signature(Required)

ADDITIONAL SERVICES:

Veterinary professionals recognize the beneficial effects of pain management in post-operative surgical patients. We offer pain medication post-operatively to all our surgical patients. As we have kept our fees for routine surgical procedures relatively low, there is an additional fee according to weight, for a post-operative pain injection.

Pain Management Consent(Required)

I REQUEST P/M

I DECLINE P/M

Initial(Required)

We offer Laser Therapy. Treating an incision site immediately following surgery with laser promotes healing, decreases inflammation and quickens the recovery period. The charge for this service is $24.50.

Consent to Laser Therapy(Required)

I REQUEST laser tx

I DECLINE laser tx

Initial(Required)

We offer “HOME AGAIN” microchip transmitters for companion animal retrieval with registry in the AKC national recovery system. Microchip identification allows your animal to be identified as yours in the event of accidental loss or escape so it may be returned safely to you. Most animal shelters, Humane Society offices and major vet clinics are equipped with microchip scanners for stray animal identification. The cost of microchipping your pet and registering is $48..

Consent to Microchip(Required)

I REQUEST a M/C

I DECLINE a M/C

Initial(Required)

Dental Information

Dental Consent(Required)

I give permission to do what is medically necessary, including dental radiographs and the removal of diseased tooth/teeth. I am placing no restrictions on the medical team regarding removal of teeth and give permission for the team to remove any/all necessary tooth/teeth.

I do NOT give permission regarding radiographs or the removal of teeth at this time. If the doctor feels it is necessary to perform radiographs or remove any tooth/teeth. I request to be called prior to taking any radiographs or extracting any tooth/teeth.

Please realize that no decision can be made as to whether any radiographs need to be taken or any tooth/teeth need to be removed until your pet is anesthetized and the dental cleaning is in progress.

If you elect to be called prior to taking radiograph(s) or extracting any tooth/teeth it is essential that you answer our call immediately. Failure to answer our call may mean that the dental procedure is completed prior to speaking with you and NO extractions would have been completed.

I UNDERSTAND THAT MY PET MAY HAVE TO UNDERGO ANOTHER ANESTHETIC PROCEDURE TO ADDRESS DENTAL PROBLEMS IF CONTACT WAS NOT POSSIBLE. I ACCEPT ALL RISKS AND FEES ASSOCIATED WITH ANOTHER PROCEDURE SHOULD SUCH AN EVENT OCCUR.

Signature(Required)

Estimated Cost/Fees for tooth removal (extraction) vary with type of tooth removed, difficulty of extraction(s), and number of extractions.

Extraction	Estimated Price
Dental Extraction -Canine	$ 38.50 ea.
Dental Extraction - Carnassial	$ 46.00 ea.
Dental Extraction - Molar	$ 29.50 ea.
Dental Extraction - Premolar	$ 10.90 ea.
Dental Extraction - Incisor	$ 7.30 ea.
Oronasal Fistula	$ 45.50 ea.
Root Canal	$ 415.00 ea.
Consil Application	$ 44.50 ea.

Dental Radiograph	$ 49.00
Dental Radiograph Add'l View	$ 19.10 ea.
Full Mouth Radiograph	$ 77.50

Extraction	Estimated Price
Extraction Deciduous Tooth	$ 21.70
Extraction Deciduous Teeth (2)	$ 33.50
Extraction Deciduous Teeth (3)	$ 45.00
Extraction of Tooth	$ 16.50
Full Mouth Extraction	$ 365.00
Full Mouth Extraction >1hr	$ 465.00

Nerve Block

$ 26.00 ea.

Untitled

Surgical/Dental Consent

Surgical/Dental Consent Form

Follow Us

Celebrating 25 Year!!!