Consent Form for Surgery/ Treatment

WhiteHouseAnimalHospital

Consent Form for Surgery/ Treatment

Owner: <first-and-spouse> <client>

Address: <address>

City, State, ZIP: <city>, <ST>, <ZIP>

Home Phone: <phone>

I am the owner or agent for the owner of the above named animal and have the authority to execute this consent. I do

consent to and authorize the following procedure(s). <appt-treatments> <appt-notes>

I authorize the use of appropriate anesthetics and other medications. I understand that the doctor will use pain medication, both in the hospital and for follow up at home, as deemed medically necessary for my pet’s welfare. I authorize the use of pain medication for my pet both during and after surgery. ______I authorize the use of LLLT (low level laser therapy) for pain and healing time reduction. LLLT Cost $24.00______,

I authorize the use of anesthetics but do not use pain relieving medication or LLLTon my pet. ______

I understand that although all reasonable precautions and due care will be taken; there is always a potential risk with anesthesia and surgery. I accept these risks and authorize White House Animal Hospital to perform such treatment as deemed necessary. I assume financial responsibility for all charges incurred to patient, and if there is a financial limit, I have indicated that here. ______

I understand that there may be an additional charge if the pet is inheat, pregnant, or has excess fat or mature organs.

What you should know about anesthesia and your pet.

Because there is always the possibility that a physical exam alone will not identify all of your pet’s health problems, we strongly recommend that a pre-anesthetic profile (a combination of tests) be performed prior to anesthesia. To ensure your pet can properly process and eliminate an anesthetic, we run these tests to confirm that your pet’s organs are functioning properly, and to find hidden health conditions that could put your pet at risk. The cost for this is $46.25for blood chemistry or $73.02 for blood chemistry and a complete blood count.

Initial here to ACCEPT these tests ______Initial here to DECLINE these tests______

Please read and initial

Both hospital policy and state law require that pets be current on Rabies vaccinations. If you are unable to provide us with written proof, one will be administered to your pet. The cost for this with aWellness examination is $59.82______.

We strongly recommend that all dogs and cats also be current on other important vaccinations and tests, those are:

*Mandatory if more than 3 months overdue at the Veterinarian’s discretion.

DogsCats

Rabies VaccineAccept______Decline______Rabies VaccineAccept_____ Decline _____

*Canine DA2LPPC (distemper, parvo)Accept _____ Decline _____*Feline DistemperAccept _____Decline _____

*Bordatella (kennel cough)Accept _____ Decline _____Feline LeukemiaAccept _____Decline _____

Canine Influenza H3N8Accept ______Decline _____Fecal / Parasite ExamAccept _____ Decline _____

*Fecal / Parasite Exam Accept ______Decline _____

Heartworm TestAccept _____ Decline _____

Please read and initial

If fleas are seen on your pet, he/she will have a flea product applied or given for the protection of all pets in the hospital. The cost for this treatment ranges from $6.00- $25.00 (depending on size and product used)______

Please read and initial

Payment is necessary before patients can be released from the hospital. I have read and understand this authorization and consent form.______

Owner/ Agent please sign: ______Date: ______

Preferred Contact method today 1. Phone ______2. Text______3. Email______

Reminders for <animal>

<treatments>