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(802) 885-2505

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About Us
Contact

Surgery Consent Form

PLEASE REVIEW THIS FORM, INITIAL TREATMENTS, & SIGN THE AUTHORIZATION.

Pet's Name:*

PT Acct#:

DOB:*

Procedure:*

1. Pre-anesthetic blood work: This is done to make sure that your pet’s liver and kidneys are functioning well, that he/she is not anemic or dehydrated, and (in our younger pets) to check for congenital problems such as a liver shunt or kidney dysplasia. This blood work is RECOMMENDED for all our patients and REQUIRED for all patients 6 years of age and older.*

	Accept	Decline
Health Screen Profile: 0-6yrs = Recommended; >6yrs = REQUIRED
Health Screen Profile and CBC: 0-10 yrs = Recommended
Full Chemistry Profile and CBC: 10+ yrs = Recommended

2. Feline Leukemia and Feline AIDS Test: We recommend a blood test for Feline Leukemia (FeLV) and Feline AIDS Viruses for ALL kittens and any cat that may have been exposed. Exposure can occur in multiple ways, including from mother to kitten, breeding, and from an infected cat’s bite. FeLV and Feline AIDS are viruses that suppress the immune system. FeLV can also cause cancer in infected cats. Both are potentially fatal and contagious. However, in the early stages, a cat with leukemia or AIDS may look completely normal.*

Accept

Decline

3. Retained Deciduous (Baby) Teeth: We recommend retained baby teeth be extracted if your pet is 6 months old or older. Retained baby teeth will cause early dental disease if left in. These retained teeth are unlikely to fall out on their own after 6 months of age. The charge is based on the amount of time required to extract these teeth.*

Accept

Decline

4. Microchip: We recommend that all pets have a means of permanent identification, such as a microchip implanted under the skin, to help locate a lost pet’s owners. Virtually all humane societies and animal control agencies scan lost pets for microchips. ***E-Mail Address required to register if Accept*

Accept

Decline

5. Consent: I am the owner/agent for the above animal, and I authorize and request the services listed on this form and/or outlined on the surgery estimate. I am aware that there are certain risks and complications associated with anesthesia, surgery, and medications, even with an apparently healthy animal. Complications can occur before, during and/or after surgery and could range from mild discomfort up to and including death. I authorize the use of appropriate anesthesia and pain medication as needed before, during and after the procedure. I understand that hospital support personnel will be used as deemed necessary by the veterinarian. I further understand that I will be charged for flea medication and a dose will be applied if evidence of fleas is found on my pet today.

Please type your full name in the space below which will serve as your signature on this document.*

Client Signature:
Date:
Phone Number Where I Can be Reached Today:

Springfield Animal Hospital

346 River Street
Springfield, VT 05156

phone: (802) 885-2505
fax: (802) 885-7066 • email us

Serving the Springfield, VT area, including (but not limited to): Ludlow, Chester, Claremont, and Charlestown.

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