Surgical Consent Form

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone # where you can be reached today*

Email

Patient's Information

Name*

Species*

Sex*

Age

Color

I, 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 Dr. Lori Willis, Dr. Lindsay Seffens, and Dr. Kelly Jeffers DVM, her agents, servants, and/or representatives full and complete authority to perform the surgical procedure described as

*

and to perform any other procedure that, at their discretion, may be useful to promote the health of the above-described pet, and I do hereby and by the presents forever release the said Doctor, her agents, servants, or representatives from any and all liability arising from said surgery on said animal.

For most anesthetic procedures, to ensure your pet’s safety and comfort, we recommend the following services:

1. Pre-anesthetic Bloodwork*

Our greatest concern is the well-being of your pet. Some conditions, including disorders of the liver, kidneys and blood can only be diagnosed through blood testing. As most anesthetics are processed through the liver and kidneys, we recommend these tests for animals prior to surgery.

Please perform bloodwork (additional $120.00)
I decline bloodwork at this time

2. Microchip*

A microchip is a safe, permanent identification for your pet. It is an injection under the skin that increases the likelihood that your pet will be reunited with you if they are ever lost.

Please microchip my pet (additional $61.80)
I decline a microchip at this time

3. Dental Procedures (If Applicable)

Extractions

I authorize all medically necessary extractions be performed
I prefer to be called before any extractions are performed. If I can not be reached, I authorize you to proceed with all necessary dental procedures
I prefer to be called before any extractions are performed. If I can not be contacted by phone, I do NOT authorize any extractions to be performed

*Please be aware that if you decline any needed procedures at this time, your pet will need a second anesthesia at another time for those procedures to be performed.

E-Collar*

E-collar: An Elizabethan collar also known as an E-collar are plastic or fabric hoods or cones placed around the head to prevent an animal from licking at a surgery site, wound, or dressing.

Please provide an E-collar for my pet (additional $24.00)
I decline an E-collar at this time

Name/Signature*

First Last

Today's Date*

Patient's Information

CONTACT.

Address

Phone