Surgical Consent Form

Pet Name*

Pet Species*

Cat

Dog

Other

I can be reached at the following phone numbers between the hours of 8:00 and 1:00 pm during which the procedure will be performed.*

I am authorizing the following procedure(s)

Please check the box next to each statement below once you have read it (All are required)*

Pre-surgical blood work and physical examination will enable us to assess and minimize the risks associated with anesthesia for your pet.

Preparation – The skin around the surgical site will be clipped and scrubbed with antiseptic. We follow sterile procedures (surgical prep, surgical packs, and surgical attire).

Monitoring - We further minimize risk by monitoring heart rate and rhythm, respiration rate and quality, oxygenation, and depth of anesthesia during the procedure. We have licensed technicians monitoring.

Pain management - We are proactive with appropriate pre-op, intra-op, and post-op pain management medications.

Fluid therapy: IV Catheter or subcutaneous fluids- To support kidney function and blood pressure during anesthesia, we include fluids administered either through an IV catheter or subcutaneously.

IV catheter does leave a small shaved spot on a front leg. Initial for consent to shave a spot for catheter.*

Initial Above

Sex of Pet*

Male

Female

Is your pet on any medication at home already?*

Yes

No

Would you like your pet microchipped during their procedure(s)?*

Yes

No

Already Microchipped

I have been shown a treatment plan for this procedure(s).*

Yes

No

I authorize anesthesia/surgery for my pet. The nature and risks of this procedure have been explained to me. I understand that some risks always exist with anesthesia and/or surgery, and I am encouraged to discuss any concerns I have about those risks with my veterinarian before the procedure(s) are initiated. My initials on this consent form indicate that any questions have been answered to my satisfaction.*

Initial Above

I authorize hospital to perform any additional diagnostic, treatment, or surgical procedures deemed necessary for medical or surgical complications or otherwise unforeseen circumstances. While hospital provides the highest quality of anesthesia monitoring and surgical services, I understand that there are rare complications with any anesthetic or surgical procedure. My initials on this consent form indicate that no warranty or guarantee has been given to me as to the results or cure afforded by these treatments or procedures.*

Initial Above

I understand that if my pet is kenneled overnight, there are no staff members present after hours.*

Initial Above

My initials on this consent form indicate that I fully understand these risks and understand that the veterinarians and hospital staff will try to minimize such risks. I will not hold Coventry Veterinary Clinic, the veterinarians, or any staff member liable for any complications that may arise.*

Initial Above

E-collars will be sent home as a part of the procedure, prices and size will vary.*

Initial Above

I HAVE READ AND UNDERSTAND THIS AUTHORIZATION AND CONSENT.*

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