Surgical Consent Form

** OWNER OF THE PET MUST BE THE ONE FILLING OUT PAPERWORK, IF THE NAME ON THE PAPERWORK DOES NOT MATCH THE ACCOUNT WE WILL NOT PROCEED WITH SURGERY. This clinic is a flea free clinic. If we notice your pet has fleas we will administer Capstar that will last 24 hrs. It will be an additional $6.

Owner's Name*

First Last

Date*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Pet's Name*

Species*

Dog
Cat

Pet Info*

Age	Male / Female	Breed / Color

Preferred Phone*

Emergencies Only Phone*

Procedure

I authorize this procedure

Spay (females)

Procedure

I authorize this procedure

Neuter (males)

Procedure

I authorize this procedure

Front Declaw (Exam mandatory prior)

I understand that anesthesia may be used and that with anesthesia there is always a risk, although minimal, of an allergic reaction or even death of the animal. A brief pre-surgical exam will be done on all animals prior to surgery to assess surgery risk. However, it is YOUR responsibility to notify us of any additional health concerns that you are aware of. Any animal found to be at risk for surgery will not be operated on until the owner has been notified of the concern. The nature of the surgery/ procedure has been explained to me satisfactorily. I assume all financial responsibility for all services rendered and payment will be expected at the time of the patient’s release.

Pre-Surgical Bloodwork ($18): This doctor recommended bloodwork is for all animals. It tests four levels in your pet’s blood and will be done prior to sedation. It not only helps us better assess anesthesia risk, but will also help us monitor your pet’s health while they are with us. This bloodwork evaluates: kidney function, red blood cell level, blood protein, and blood sugar levels. Check one or the other.

Bloodword*

I want this bloodwork
I don't want this bloodwork

Please check to consent to one or the other.

Dog Optional Items

Rabies Vaccine ($15)
Distemper Parvo Combo Vaccine ($16)
Leptospirosis only ($16)
Bordetella Vaccine ($16)
Influenza Vaccine ($28)
Microchip ($35)
Heartworm Test / Flex 4 ($30)
Nail Trim (Free)

Cat Optional Items

Rabies Vaccine ($15)
Upper Respiratory Combo Vaccine ($16)
Leukemia Vaccine ($21)
FIV / Leukemia Test ($36)
Microchip ($35)
Nail Trim (Free)

Anesthesia Consent

As the owner or agent of the owner of the animal above, I hereby give my consent to Bethel Animal Health to perform the following procedure*

It is our goal to keep all procedures as reasonably priced & as safe as possible. Our base price includes the services that we feel are most important for a successful surgery and comfortable experience for your pet. There are several other services that we feel are important to offer for safety & comfort. They are available at an additional fee

1. IV catheter- The IV catheter provides quick access to the veins in case of an emergency and assists in administration of IV medications. Fluid therapy can help stabilize and support healthy blood pressure.

IV catheter only: $30*

Approve
Decline

IV catheter plus fluid administration during procedure: $50*

Approve
Decline

2. Elizabethan Collar- This is a lamp shade cone that goes on your pet's neck to prevent licking/chewing of the surgical site. An e-collar is highly recommended to prevent post-operative damage to the surgical site. The owner is held financially responsible for all post-operative care needed as a result of not purchasing and e-collar or other post-operative needs.

E-Collar cost: $10.50-$16.00*

Approve
Decline

3. Additional Anesthesia monitoring package - (Electrocardiogram & blood pressure)

All surgical patients are monitored with a pulse oximeter, which reads their heart rate and blood oxygen levels during surgery. The additional monitoring package includes additional electrocardiogram (ECG) and blood pressure monitoring. An ECG assesses the heart function during anesthesia.

Additional Monitoring $50*

Approve
Decline

If your pet has fleas it will be treated with a fast acting (24hr Effective) flea control in our hospital. Fleas are easily spread and put your pet and other pets here at risk. If the veterinarian deems it necessary to administer Capstar you will be obligated to a $6 fee. (Initial for understanding)*

I certify that I own the above described animal and authorize Bethel Animal Health to hospitalize/treat said animal. During this time they may administer vaccinations, medications, tests, surgical procedures, anesthetics, or treatments they deem necessary for the health, safety, and wellbeing of my pet while the care and supervision of the hospital. I understand there are inherent risks associated with anesthetics, medical and surgical procedures, including death. I authorize the doctors of Bethel Animal Health to initiate care to address complication, should they arise while under their care. In the event of an emergency, the hospital will make every reasonable attempt to contact me so that I am aware of the situation, so I am involved in medical decisions. The contact phone numbers in my chart are correct. If my pet should injure itself in an escape attempt, refuse food, soil self, become ill, or die while in the hospital, I will hold Bethel Animal Health and staff free of all responsibility and/ or liability in the absence of gross negligence.

I further realize that I am responsible for payment of all above mentioned procedures/ treatments in full at the time of my pets discharge. If I neglect to pick up my pet within 7 days of notice that my pet is being released, Bethel Animal Health may assume that the animal has been abandoned. In such instances, Bethel Animal Health is then authorized to take care of my pet as they see fit, including euthanasia or adoption. Abandonment however, does not release me of the responsibility of my obligation for payment of said bill.

Please bring any medical records with you. All cats should be in carriers.

Signature of Owner / Agent*

Anesthesia Consent

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