Snelgrove Veterinary Services | Surgery Consent Form

Date of Surgery or Procedure:*

Time*

Last name:*

Patient’s name:*

Email*

Phone number on file:*

Phone number we can contact you during your pet’s stay:*

(this must be a phone number that we can reach you at in case of an emergency)

Would you like to do Pre-Anesthetic blood work the morning of the surgery?

Yes

(Pre-Anesthetic blood work is recommended because it will give the doctor a detailed overview of the health of your pet, as well as a comprehensive look into your pet's organ function. It is important to understand that a pre-anesthetic profile does not guarantee the absence of anesthetic complications, but it can greatly reduce the risk of them, as well as identify medical conditions that could require treatment in the future. The cost of this will be $118.70 )

Would you like your pet micro-chipped?

Yes

(A microchip is a small chip about the size of a pen nib that is implanted in between your pet's shoulder blades. Each microchip has a unique identification number that will link your pet to your personal details (name, address, etc.). If your pet ever goes missing, a microchip provides a fast, permanent way of identifying you as the owner. The cost of this will be $59.00.) If yes, please provide emergency contact information. This needs to be someone you trust to accept responsibility of your pet if you are not available. Preferably someone that does not live in the same household nor that you travel with.

Would you like a Medical Pet Shirt?

Yes

(A Medical Pet Shirt (MPS) is a pet “onesie” that protects wounds/sutures on the torso and is often used as an alternative to an e-collar (cone). It is made of 94% organic cotton and 6% lycra, so is comfortable, breathable and machine washable. If you choose to purchase an MPS, we will size your pet prior to their discharge time. The cost of this will be $30.00 - $40.00 depending on the size required.) Due to the nature of their use, please be aware that these are non-refundable once fitted to your pet.

My pet has been fasted since 8:00 p.m. last night

Yes

My pet has not had any episodes of vomiting, diarrhea, coughing, sneezing, or loss of appetite in the past 4 days, nor has shown any signs of menstrus (swelling, discharge, or excessive licking of vulva) and has not had any other problems/concerns, that Snelgrove Veterinary Services is not aware of:

Yes

If yes, please explain:

I, the undersigned, do hereby certify that I am the owner (or duly authorized agent for the owner) of the animal described above, and that I do hereby give Snelgrove Veterinary Services full and complete authority to perform the surgical procedure described as:

Sign and date here . Please be advised that this form is only valid on the date of surgery. Filling it out prior to this date will render this form invalid and it will need to be resubmitted on the day of surgery

ONLY VALID ON DAY OF SURGERY - Surgery Consent Form