Surgery/Anesthesia Consent Form Surgery/Anesthesia Consent Requested Surgery or Procedure(s) * Owner's Name * Owner's Name First First Last Last Pet's Name * Age * Was estimate provided prior to appointment * Yes No Additional Procedure(s) Date of Last Heat Cycle Would you like your pet microchipped at the time of this procedure? Yes No Pre-Op Blood Work: (Recommended for all pets, Required on all pets 6 yrs or older) Yes No Surgical Fluids: (Recommended for all pets, Required on all pets 6 yrs or older) Yes No Would you like your pet vaccinated at the time of this procedure? Yes No What Vaccines are needed Would you like a heartworm test performed at the time of this procedure? Yes No Anything else you would like us to do? Preferred Pick-up time * I verify that I am the owner (or authorized agent for the owner) of the above-named pet and authorize the above procedure to be performed. I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian. I have been advised as to the nature of this procedure to be performed and the risks involved. I understand also that there is always a risk associated with any anesthesia, even in apparently healthy animal and have discussed my concern with the veterinarian. I understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated for the safety or care of my pet. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian's professional judgment. I agree to be responsible for any charges incurred while my pet in in the care of Yellow Dog Veterinary Clinic and understand that payment is due at the time my pet is released from the clinic. I understand no staff will be attending to my pet overnight (pets needing special care may be referred to a 24-hour hospital). Signature * signature keyboard Clear Date * Phone/Text Number * Email * Submit Captcha If you are human, leave this field blank.
