Surgery or Anesthesia Consent | Animal Hospital of Montgomery

Client Name *

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Last

Patient Name *

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Female

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A technician may call you on the day of services to confirm all information on this form. This should be the best number to reach you.

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Anesthetic and surgical procedure(s) to be performed: *

I, the undersigned owner or agent of the pet identified above, authorize the staff of to perform the above procedure(s). I understand that some risks always exist with anesthesia and/ or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. I understand that the attending veterinarian will make every effort to contact me regarding treatment in the case of unforeseen emergencies. If unable to contact me, the staff may or may not have my permission to proceed with life sustaining procedures. *

Yes, I give my permission
No, I do NOT give my permission

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow up radiographs, re-check physical exams and additional surgery due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions. A complete physical exam will be performed on your pet prior to the surgical procedure. However, this may not identify all systemic or metabolic problems. For this reason, your pet will have a pre-anesthetic blood panel to evaluate major organ functions prior to anesthesia unless you have specifically elected not to have it performed. *

Yes, I Agree
No, I do NOT Agree

Do you have a doctor preference to perform your pet's procedure?

Yes, I have a preference
No, I do NOT have a preference

Name of Preferred Doctor for Procedures:

I have read and fully understand the terms and conditions set forth above. *

Pre-Surgical Blood testing (Additional Cost)

Pets less than 7 years of age: Blood work is strongly recommended. *Pets 7 years of age or older are required to have Blood work*

Comprehensive Profile w/ CBC & Electrolytes - $152.25

Accept
Decline

As your pet ages, blood work becomes more important. This profile rules out anemia, infection & dehydration and informs us of how the kidneys and liver are functioning as well additional enzymes that are important in anesthetized patients. Once your pet reaches 7 years of age it becomes mandatory at AHM to perform this profile.

My pet has had pre-surgical/anesthetic blood work within the last 21 days, and has been approved for anesthesia by Doctor.

Yes
No
I don't know

I DECLINE all blood profiles at this time and accept any and all responsibility in the event there are complications that could have been avoided by doing the blood profile.

Yes, I DECLINE and take responsibility

IV Catheter and Laser Therapy: A catheter is placed in your pets leg for immediate access in the event of complications. Fluids are administered through the IV catheter if it is necessary during the procedure. It helps maintain blood pressure and keep the electrolytes balanced during surgery. Laser Therapy is an application of multiple light waves delivered to the surgical site to aid in the speed of the healing cascade. Most surgical procedures will be monitored with continuous ECG while they are under anesthesia. *

Yes, I understand
No, I do not understand

Any pet with fleas/ticks will be treated for an additional charge *

Yes, I understand
No, I do not understand

There will be additional costs for pets with retained baby teeth, male pets with retained testicles and female pets that are pregnant or in heat. *

Yes, I understand
No, I do not understand

Additional Procedures to be performed

Please select the box to accept the following procedures. Unchecked boxes DECLINE procedures listed below.

Feline Lkv/FIV/Fe Hw Test: $63.95
Heartworm Erlichia Lyme Test: $55.70
Fecal Test: $42.00
Vaccinations: Cost Varies
Pain Medication (to go home): Cost Varies
Nail Trim: $13.25
Ear Cleaning/Plucking: Varies
Microchip: $68.40
Dental Cleaning add-on to Surgery: $160-$220
Tooth Extractions: $13-74 each
Histopathology 1 site (FBX1): $250.96
Elizabethan Collar: $10-$50

If you did not check any boxes above, those procedures are declined.

List any questions regarding additional procedures seen above.

PLEASE READ EVERYTHING BEFORE SUBMITTING. Type your name below if you acknowledge that you have read and understand the above described information and accept all fees that your pet will incur while in the care of the Provider.

Type your name. Your signature will be added in the office upon dropoff.