Pet's Name (required) Who is available to be contacted if there are any questions or concerns on the day of surgery? This must be someone who can make decisions about your pet.(Someone MUST be available to contact between 8 am and 5 pm) (required) What phone number can we contact this person at between 8 am and 5 pm? (Can provide multiple numbers) (required) Did you receive and review the Care Plan / Estimate from us for your pet's procedure in the past week? (required) Yes, and I agree to the estimate Yes, but I have additional questions No, please resend it
A 3-5 day course of a routine anti-inflamatory/pain medication will be dispensed and is included in the cost of surgery. If the veterinarian feels like my pet required more or a stronger pain medication(s), there will be an additional charge for this. (required) I understand I will be responsible for the fees associated with these, even if they are not included on the Care Plan/Estimate
Intravenous Fluids help maintain blood pressure, hydration, and good organ function while an animal is anesthetized. This is typically required for most anesthetic procedures and is likely included on your estimate. Did you have any additional questions about IV Fluids? (required) No, please proceed as planned Yes, please contact me to discuss further
If your pet is young, healthy and having a routine surgery, Bloodwork may be optional for your pet. It is highly recommended to make your pet’s anesthetic procedure as safe as possible. We wish we could include this in the basic package for every pet, but we realize that many people have financial concerns and we feel
an obligation to keep our surgery prices affordable for everyone.
We offer the best level of care possible while giving you, the pet owner, control to make the decision for your individual circumstances. Many conditions, including disorders of the liver, kidneys, or blood, are not evident physically but could possibly lead to complications. The tests will help to check many things including the function of the liver and kidneys, which are vital to eliminate medications used for anesthesia. These are the same tests your doctor would perform on you before any routine surgery. Our laboratory equipment allows us to run these tests within minutes. If the results are abnormal, we will call you to discuss options and if normal, they will give us and you peace of mind to proceed with anesthesia today. If Pre-anesthetic Bloodwork is shown as optional on your pet's Care Plan / Estimate, did you receive the handout discussing Bloodwork in more depth? Yes, and I understand the information Yes, but I would like to discuss further No, please send it to me If Pre-Anesthetic Bloodwork is optional for your pet: Yes, I would like it performed prior to surgery and I understand there is an additional cost for this as shown on the Care Plan. No, I decline bloodwork and I understand there could be complications due to underlying disease not being caught prior to surgery.
All pets are required to be current on Rabies Vaccine as well as Distemper Combo Vaccine to be in our hospital for the day. If your pet is not current, it will be updated on these vaccinations, at your expense. By 'signing' at the bottom of this form, you understand and agree to this. OTHER VACCINATIONS: There are other optional vaccinations that may be suggested for your pet, such as Leptospirosis Vaccine (typically administered with Distemper Combo), Lyme Vaccine, Bordetella (Kennel Cough) Vaccine, Canine Influenza Vaccine. I would like the following vaccines to be administered today for an additional fee. (Choose all that apply) Leptospirosis Lyme Bordetella (Kennel Cough) Canine Influenza Please adminsiter and boosters that my pet is due for that have been discussed in the past I would like to discuss these options further
OTHER OPTIONS (available for an additional fee):
MICROCHIP - Microchipping is a simple, safe way to know that if your dog ever strays off and is brought to any humane society or veterinary clinic in the United States, they should be easily and quickly identified and reunited with you. Yes, please administer at the time of surgery No I would like to discuss further FECAL EXAM - Intestinal parasites are common, cause many problems in our dogs and have the potential of transferring to humans. Most stay inside a dogs intestinal tract and go undetected unless a stool sample is examined under a microscope. Yes, please perform this if it has not been done recently No, I am not interested ELIZABETHAN COLLAR (E-Collar) - It is strongly suggested to take home the day of surgery to help prevent your pet from self-traumatizing their surgery site. It is suggested to keep on your pet at all times they are not being directly monitored. (required) Yes, please dispense an e-collar No, I decline an e-collar I would like to discuss further SEDATIVE MEDICATION - This is not necessary for all pets but if you feel that you may have a hard time keeping your pet quite for 7 days post surgery, we can dispense a mild sedative to help with this. Yes, please dispense this for my pet No, I am not interested I would like to discuss this further.
PREVENTATIVE MEDICATIONS - HEARTWORM / FLEA / TICK
It is recommended to keep your pet on Heartworm and Flea/Tick Prevention year round, or minimally Spring through early Winter. There are many options for preventions and we are happy to discuss them in more detail with you, if you are unaware of the options. Would you like any prevention dispensed today? Yes, I want prevention and I know what I would like (Please specify below) Yes, I want prevention, but would like to discuss further No, I do not need anything dispensed now. Please specify what preventions you would like to pick up here: OTHER - Are there any other questions you have or items that you need the day of surgery? Please describe here:
We do use various types of general anesthesia depending on the procedure to be performed, the duration of the procedure, the age, and the condition of your pet. We have certified technicians monitoring your pet during the surgery and we will use all reasonable precaution against injury, escape or death of your pet while in our clinic and under our care. (required) I understand that all anesthesia involves some amount of risk to my pet, but I will not hold Mazomanie Animal Hospital or any of its staff liable or responsible in any manner should problems arise.
By typing in my full name below, I understand I am legally signing this form and agreeing to all of the above
TYPE (TO SIGN) FULL NAME BELOW: (required) DATE: (required)