Surgery Consent Form Step 1 of 250%Date Of Appointment* MM slash DD slash YYYY Owner* First Last Pet's Name*Procedure(s):*Please initial the following:To the best of my knowledge my pet is in good health.When did your pet last receive their medications?*A physical exam will be performed on your pet prior to the procedure, but this may not identify all internal problems. It is good medical practice to perform pre-operative blood work to assess major organ function and check for other blood abnormalities. Blood work is required for pets over the age of 8.* Accept Pre-Operative Blood Work Decline Blood Work Dogs receiving monthly heartworm preventative must have had a negative heartworm test within the past year. Dogs not receiving heartworm preventative must be tested for heartworm (unless they are less than 6 months of age).* Accept Heartworm Test Decline Heartworm Test N/A Now is the perfect time to implant a microchip!* Accept Microchip Decline Microchip N/A Any other services desired such as anal gland expression?*A free nail trim will be performed. If we find external parasites (fleas, etc.) on your pet, we will treat your pet and the cost of the treatment will be added to your invoice.I, the undersigned, certify that I am the owner, or authorized agent for the owner of the animal described above. I authorize the veterinarian and assistants of Mahomet Animal Hospital to perform the procedures listed above. I understand that no surgery and no anesthesia is without risk of complications and that, although rare, there is always the possibility of loss of life. I release Mahomet Animal Hospital and its associates from any liability in such an event, i.e. injury, escape, death, or any other unforeseen circumstances. I also understand that no guarantee of successful treatment can be made. In the event of an emergency I authorize the veterinarian and assistants to provide any and all treatments/procedures deemed necessary and accept responsibility for any additional cost incurred. (Signature)*Date* MM slash DD slash YYYY Phone(s)*Payment is due when services are rendered, unless prior arrangements have been made. Account balances will be charged a $1 statement handling fee and 2% interest accrued monthly.Your pet will need to be fasted for their procedure. No food after 10 pm the night before, including no breakfast the morning of. Water is ok.Medical History Form Date MM slash DD slash YYYY Seizures? Yes No Heart problems? Yes No Allergic reactions? Yes No Drug allergies or reactions? Yes No If yes, what drug(s)?Diabetic? Yes No If yes, what type of insulin and units are given?Other serious or chronic medical issues? Yes No If yes, describeAny illness/trauma (vomiting/diarrhea, coughing, accident) in the past 30 days? Yes No Sedation HistorySedated previously? Yes No If yes, any problems?MedicationCurrently on medication(s) other than heartworm and flea/tick prevention? Yes No If yes, what medication?Heartworm prevention (dogs only)Current on heartworm prevention? Yes No If yes, what was the last date given?*If no, a heartworm test may be mandatory prior to anesthesia.Flea MedicationCurrent on flea medication? Yes No If yes, what brand and when was it last applied?Vaccination HistoryCurrent on vaccinations? If your pet is new to our hospital, please bring in vaccination records to your appointment. Yes No *If no, vaccinations may be required. Do you want vaccinations updated?Additional services Nail trim Microchip ($45, including lifetime registration) Express anal glands ($18 - $20) Other If otherYour pet will need to be fasted for their procedure. No food after 10 pm the night before, including no breakfast the morning of. Water is ok.I certify that all the information above is accurate to the best of my knowledge and that I have read and understand all the information above.Owner’s Digital SignatureCAPTCHANameThis field is for validation purposes and should be left unchanged.
