Download the canine surgery consent form.

Webberville Animal Clinic
127 North Main Street
Webberville, MI 48892
517 521-4207
CANINE SURGERY CONSENT FORM
Name:____________________________________ Pet’s Name:________________________________________
Address:_________________________________________ Best Phone Number:_________________________
E-mail (optional):__________________________________
Surgery:______________________________________ Date______________________
FOR OFFICE USE ONLY
Account #_________________
Weight:_______________ Breed:__________________ Color:________________
Fasted?_______________________
Estimate:_____________________________
PET HEALTH:
1. Has your pet had an allergic reaction to a vaccination or medication?
___________YES ___________NO
2. Is your pet currently taking any mediations? (Aspirin, allergy meds, ect.) ____________YES ___________NO
Explain:_____________________________________________
3. Has your pet ever had a seizure? _______________YES __________________NO
4. What illness has your pet had in the last 2 weeks? Coughing Sneezing Vomiting Diarrhea Weight Loss
Loss of appetite None Other:_________________________________________________
It is required that your dog be current on Rabies vaccination, proof required. Will we be vaccinating your pet for RABIES
today? Cost $15.00 ______________YES __________________NO
ADDITIONAL RECOMMENDED SERVICES:
PREANESTHETIC BLOODWORK: $56.00 _____________YES _______________NO
We recommend bloodwork for every pet before surgery/anesthesia. Animals can hide illnesses or disease well
without showing any outward signs. Bloodwork can alert the doctor or any preexisting conditions that may be
present in your pet. A blood panel can reduce the risk of anesthetic, surgical, and postoperative complications.
It screens for kidney disease, anemia, infections, liver disease, and diabetes.
ADDITIONAL PAIN CONTROL: $10.00 _______________YES _____________NO
Your pet will receive a pain injection while here for surgery today. It is recommended to take home additional
pain medication for your pet’s comfort. This can help control postoperative pain and inflammation.
DHLPP $20.00 _____________ BORDETELLA $20.00 ______________ LYME $30.00 _______________
MICROCHIP $38.00 _________________ FECAL $15.00 ________________
HEARTWORM TEST $30.00 _______________YES ______________NO
We strongly recommend that all dogs over 10 months of age be tested for heart worm disease if their status is
unknown. Heartworm is transmitted by mosquitos and your dog will often show no signs in the early disease.
Dogs that are positive for heartworm are at much greater risk of complications while undergoing anesthesia.
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E-COLLAR $17.00 _________________YES __________________NO
You have the option to purchase an e-collar to prevent your pet from licking and chewing the surgical site. Dogs
that have post incisional complications due to licking or chewing will need to be examined and receive
medications at your cost.
Please read, initial, and sign (required) the following:
________If fleas are found on your pet while at the clinic we will administer a capstar (a 24 hour flea control) during
their hospitalization for a mandatory fee of $7.00 -$35.00. Monthly flea preventative is recommended.
______I will pay a boarding fee of $25.00 per night if my pet is not picked up on the designated day. I also understand
that my pet will not have someone at the clinic attending to them overnight. A pet that is not picked up within 72 hours
of surgery is considered abandoned and will be released to proper authorities.
______I understand that my pet will not be discharged from the clinic if my balance is not paid in full. A $25.00 per night
boarding fee will be charged until the balance is paid. Any bill not settled within 72 hours of surgery will be considered
abandonment of your pet and they will be released to the proper authorities.
______I understand that there will be additional charges if my pet is found to have a hernia, be in heat, have
undescended testicles, is pregnant, or has a pyometra (uterine infection).
I hereby authorize Webberville Animal Clinic to surgically sterilize the above mentioned animal. To my
knowledge the above animal is in good health. I understand that there are risks with any anesthetic or surgical
procedure and are encouraged to discuss any concerns with the clinic staff. The clinic will provide every possible means
of care to reduce any risks of complications for your pet. My signature indicates that I am financially responsible for this
procedure and are aware of the possible additional charges discussed above. I agree to indemnify and hold harmless
the Webberville Animal Clinic and the attending Veterinarian from and against any and all liability arising out of the
performance of all procedures referred to above.
*We except cash and credit card, including care credit, for payment. No checks please.
Pet Owner’s Signature _________________________________________Date______________________
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