Surgery Consent Form

Have you noticed any:

Changes in Appetite or Thirst:

Changes in Body Condition:

Changes in Energy Level:

Vomiting/Diarrhea

Coughing or Sneezing:

Exercise Intoleranced

If yes,please elaborate:

Has your Pet ever experienced:

Anesthetic complication

Drug/vaccine reactions

Serious illness/injury/disease

If yes,please elaborate:

When was thelast time the patient had any food?

Listanyandall medications,prescription and over the counter:

Would you like your Pet to receive:

HomeAgain Microchip with lifetime registration(52)

In the unlikely case of a life threatening emergency...

I consent to extreme measures including but not limited to CPR manual respiratory ventilation,and drug treatments to be taken to prevent death.($300-$500)

I do not consent to extreme measures to be taken to prevent death; do NOT resuscitate.

I understand that if while under anesthesia,a condition is which requires additional procedures including not limited to pregnancy termination,toothextractions,and hernia repair the veterinarian may perform such procedures at his/her discretion at my expense.

- It is necessary that all dogs are current on the following: Rabies, DHPP & CIV (Both H3N2 & H3N8). The following are required within the last 6-months: Exam ,Bordetella and fecal exam.
- It is necessary that all cats are current on the following: Rabies & FVRCP. The following are required within the last 6-months: Exam and fecal exam.

I, being of legal age and responsible for the patient listed above, give consent to Louetta Veterinary Medical Center of Spring (VMCS) to treat and perform surgical procedures under anesthesia upon the patient listed above. I understand there is an inherent risk in association with anesthesia and sedation; risks may include but are not limited to infection, hemorrhage, and even death. I understand VMCS is not held responsible for risks that may arise in association with a nesthesia or sedation. I understand that additional treatmentmay be required if an E-collaris not used as directed and injury occurs at the patient’s incision site at my expense. I understand payment is due at time services are rendered and no payment plans are offered at VMCS. By signing below, I agree to all statements above and agree that all information I supplied on this document is true.

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Surgery/Anesthesia Consent Form

Surgery/Anesthesia
Consent Form