Surgical Consent Form START NOW Surgical Consent Form Please enable JavaScript in your browser to complete this form.Client Name *Email *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Patient's name *Species *Breed *Sex *Weight *List of procedure(s) to be performed * I understand that a pre-surgical blood panel is required to maximize safety before anesthetizing your pet. This will help the veterinarian identify any pre-existing problems that are not evident during a routine pre-surgical exam and the cost is included with the package. * I understand that intravenous fluids provide additional supportive care for your pet, keep them hydrated, and aid in flushing the anesthesia from your pet's system. These IV fluids are required for the procedure and cost is included with procedure package. * I understand that all pets undergoing surgery must be fully vaccinated. Proof of your pet's most current vaccines is required. If there is no proof provided, your pet will be vaccinated at the time of the procedure at an additional fee. * I understand that if fleas and/or ticks are found on my pet during the pre surgical examination treatment will be required at the time of the procedure at an additional fee. EFFITIX FOR DOGS AND PROVECTA FOR CATS *I understand that female patients undergoing a spay surgery and found to be in heat, will be charged an additional fee. * I understand that male patients undergoing a neuter surgery and found to be cryptorchid (retained testicle) will be charged an additional fee dependent on the number of retained testicles. * I understand that post-operative pain medications and or antibiotics will be sent home for the comfort and safety of your pet, at the discretion of the attending veterinarian. These items are not optional and will be added to the invoice and due at time of release. *CERENIA INJECTIONCerenia is an anti-emetic that will prevent pre-operative nausea and help your pet return to normal feeding, therefore resulting in a faster recovery. This is an additional cost that will be added to the invoice and charged at time of release. *YesNoCBCComplete Blood Count of the red blood cells (which carry oxygen), white blood cells (which help fight infection) and platelets (cells critical to the blood's ability to clot). *YesNoI authorize Tillema Veterinary Clinic's staff, in an emergency situation, to perform any additional procedures necessary for the well-being of my pet until further communication with me. IF UNABLE TO CONTACT ME: * I give my permission (yes)I do not give my permission (no) to proceed with life sustaining procedures. I do hereby certify that I am the owner/agent of the pet listed above. I give my consent to Tillema Veterinary Clinic and it's staff to care for and administer any treatment and/or perform any tests deemed necessary for the health and welfare of my pet. I do hereby release Tillema Veterinary Clinic and it's staff of any responsibility and liability, in the absence of gross negligence, should my pet inflict self-injury, refuse food, become ill, or die while in the care of Tillema Veterinary Clinic and it's staff. I am aware of the risks involved with anesthesia and that the results cannot be guaranteed. There may be times that no personnel are on the premises and that transfer for continued care may be required. I understand that Tillema Veterinarian reserves the right to cancel or postpone the procedure under veterinarian discretion. *I have read and understand.I have read and completely understand this consent form and by signing this document I authorize the Veterinarian and the staff of Tillema Veterinary Clinic to perform the procedure(s) as indicated. All charges are due upon release. I understand that a deposit of half of the balance is required at time of drop off and the balance is to be paid at the time of pick up. I accept any additional charges that may incur from the items discussed above and agree to the statements listed above. *I have read and understand.Signature Owner/Agent Clear Signature(18 years or older)Submit
