Download Surgery Consent Form Pre-Anesthetic Blood Test IV Fluids IV Fluids

Country Animal Hospital
Hermiston, OR 97838
(541) 567-6086
Surgery Consent Form
Owner: _______________________________
Patient’s Name: ________________________
Date: ___________________
I, the owner or authorized agent for the above described animal, authorize the following
procedure and the use of appropriate anesthetics, and other medications, and I understand
that hospital staff will be employed as deemed necessary by the veterinarian.
Today’s Procedure(s): _________________________________ Initials: _________
Estimated cost without any additional options $__________________
Surgery Option 1
$85
Pre-Anesthetic Blood Test
Why is this important? This test can help alert us to some of the more common problems allowing extra precautions to
be taken with your pet’s anesthesia.
A blood test can be perform before your pet undergoes anesthesia, to test the functioning of the kidneys and liver, the key organs that
help filter the anesthesia.
IV Fluids
Why are IV Fluids Important?
IV Fluids help to help prevent shock, and protect kidney function lessening the chance for complications during surgery.
Estimated cost of today’s procedure with these options $___________________________ Initial________
Surgery Option 2
$30
IV Fluids
Why are IV Fluids Important?
IV Fluids help to help prevent shock, and protect kidney function lessening the chance for complications during surgery
Estimated cost of today’s procedure with IV Fluids $________________ Initial_________
Heroics
Should complications arise during your pet’s procedure we need to know if you have any financial restraints that would prohibit
Dr. Burgess from administering lifesaving treatments. The cost of this service depends upon the severity of complications
Appropriate treatment will be done unless otherwise noted below:
_____Please perform lifesaving treatments on my pet.
_____Please do not perform lifesaving treatments on my pet.
Required Charges if Applicable
Fleas Treatment - Any animal found with fleas will be required to be treated $20.00
Restraint - If your pet is feral, fractious or aggressive and additional restraint is required, an extra restraint fee of $20.00 will be applied.
In Heat/Pregnant/Obese - If your pet is in heat, pregnant, or obese an extra fee will be applied.
I have read and understand this authorization and consent. I agree to the financial terms and policy of
Country Animal Hospital. I understand that Country Animal Hospital does not carry accounts and
payment is expected when my pet is discharged.
 Owner’s Signature __________________________________ Phone # for today____________________