Country View Veterinary Service
1350 S. Fish Hatchery Rd ♦PO Box 27♦OregonWI53575
Pre Surgical /Dental Consent Form
Owner’s Name: / Species/Breed:Patient’s Name: / Sex/ DOB / Age:
I am the owner or the agent for the owner of the animal described above, and I have the authority to execute this consent. I hereby consent and authorize Country View Veterinary Service (Drs. Olson, Gunby, Kasten) and their staff to perform the following procedures or operations:
Bloodwork
Before putting your pet under anesthesia, we will perform a full physical exam. However, some conditions, especially disorders of the kidneys, liver, or blood may not be evident unless additional tests areperformed.
Juvenile Health Profile Adult Anesthesia Panel Comprehensive Panel CBC (anemia, infection, platelets) CBC CBC
Brief Chemistry Full Chemistry Full Chemistry/Electrolytes (Key kidney, liver, glucose, protein) Electrolytes Complete Urinalysis
Electrolytes. Urine Screen Fecal Panel
Thyroid level
4Dx (canine)/Feline Triple
____ I elect to refuse the recommended pre-anesthetic blood work at this time and request you proceedwith anesthesia.
____ Blood-work done on ______
IV Catheter and Fluids – Standard for Anesthesia
Fluids given during anesthesia can help to keep the blood pressure normal and the IV catheter allows instant access to a vein in the case that medications need to be given. IV fluids can also help to cleanse the body of anesthetics in the post-anesthetic period.
Microchip – yes no
Fluoride Treatment (Patients <1yr.) – yes no
Dental Consent:
____ If further dental work is needed beyond a cleaning and polishing, I authorize Country View Veterinary Service to perform necessary procedures (extraction of infected teeth, biopsy of mass).
____ Please call for my consent if further dental work is needed. I will be at the phone number listed below.
If I cannot be reached I authorize up to $______. If I cannot be reached, then do not proceed with any extractions/biopsy. I understand further procedures may need to be completed on another day.
The nature of these operations or procedures has been explained to me, and I understand what will be done. I have also been informed and understand that there are certain risks and complications associated with anesthesia and any operation or procedure of this type. I further understand that during the course of the operations or procedures, unforeseen conditions may arise that may necessitate the performance of additional procedures.
I authorize the use of appropriate anesthesia and pain relief medication as needed before and after the procedure. I have been informed that there are risks associated with the use of any medication.
I assume full financial responsibility for this/these animal(s).
Signed: ______Date: ______
Today’s Phone #s: ______/______Discharge Time: ______