Surgery Consent Form | Animal Medical Center Brookhaven

IMPORTANT:

In order to establish and maintain a sterile surgical field during your pet’s surgery, your pet MUST be free of fleas, ticks, and other external parasites prior to surgery.

Pet History

Has your pet eaten this morning?(Required)

Is your pet allergic to any drugs?(Required)

Has your pet had any illness or injury in the past 30 days?(Required)

Has your pet had any history of seizures or previous anesthetic problems?(Required)

Current medications:

List medications your pet is allergic to:(Required)

Upcoming Procedure(s)

Procedure to Be Peformed:

Elective Procedures to be Done:

Pre-Anesthetic Blood Screen

A pre-anesthetic blood screen is recommended for your pet's safety. The results of this blood screen will help our Doctors evaluate your pet's anesthetic risk and your pet's clotting ability. The fee for this procedure is an additional $105.00.

Untitled(Required)

I request a Pre-Anesthetic Blood Screen for my pet

I chose to decline the Pre-Anesthetic Blood Screen

Owner Authorization & Release

I understand all anesthesia and surgeries involve some potential risks and complications for my pet. I agree to pay for all services rendered at the time of discharge of my pet, including any flea, tick, or external parasite treatment(s) prescribed and administered to my pet prior to or after surgery. I have read the foregoing, understand what it says, and agree to all terms of this consent form.

Owner Signature(Required)

First Last

Daytime Phone Numbers:(Required)

To list more than one number, press the '+' icon.

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