Surgical Authorization Form Authorization for Surgical Procedure AUTHORIZATION FOR SURGICAL PROCEDURE Name Name First First Last Last Email * Phone * Pet Species Canine Feline Patient Name * Date of Scheduled Procedure * Please note: It is extremely important that we are able to reach you during your pet’s procedure. Surgical Procedure * - Select One -Spay/NeuterDentalGrowth RemovalTPLOOther Surgical Procedure BLOODWORK REQUIREMENTS We require a pre-anesthetic blood screening prior to surgery to ensure your pet's safety during anesthesia. By performing this important blood work, we will be able to rule out any pre-existing Internal problems that may not be evident physically; but could lead to serious complications. Pre-Surgical Bloodwork * Has already been completed and deemed within normal limits My pet needs bloodwork to be done prior to the surgical procedure VACCINATION REQUIREMENTS Vaccinations My pet is current on their rabies vaccine (with proof) My pet needs a rabies vaccine I understand my pet must be up to date on all required vaccines unless waived by the veterinarian. * I understand Feline Viral Screen Testing to be performed: (Tests for Feline Leukemia and FIV) Yes No CANINE REQUIREMENTS The following does not apply to felines. Heartworm Test (Canines) My pet has a current heartworm test and is on monthly prevention (with proof) My pet needs a heartworm test My pet does NOT need a heartworm test because they are under 6 months N/A – my pet is NOT a dog Required for patients over 6 mos. of age, not on prevention. The presence of heartworms greatly increases the patients’ risk of complications during anesthesia. I understand that my dog is over the age of 6 months must have current heartworm screening and be on prevention consistently. If not, a heartworm screening will be needed prior to my pet receiving anesthesia. * I understand I understand an IV Catheter and IV Fluids is required for my pet’s surgery: (*Feline Neuters do not have this requirement*) * I understand Dental Procedures For Dental Procedures * I authorize the doctor to extract any teeth deemed necessary without further authorization I prefer to be contacted prior to extractions of any teeth. I understand if I cannot be reached during the procedure, the doctor WILL NOT extract any teeth Would you like to view pictures of your pets pre and post teeth cleaning at discharge? Yes No Additional Services I would like my pet to receive today I understand if my pet is admitted with fleas they will receive a Capstar treatment that I am financially responsible for * I understand Would you like your pet to receive a Datamars microchip today? * Yes No Adding Advanced Life Saving Care option Yes No While our team utilizes the most up to date surgical and anesthetic protocols, monitoring, and training, any and all anesthetic procedures do have an inherent risk associated with cardiac and/or respiratory distress. In the event of an unforeseen situation while under our care, would you like for our team to pursue Advanced Life Saving care until our team can contact you? Authorization Agreement I hereby authorize the requested surgical procedure, blood work, and/or services indicated above. I understand that I assume financial responsibility for all services rendered, and that payment is due at the time of release from the hospital. Although we employ the highest level of anesthetics and surgical standards, I understand there is always a risk with anesthesia and unforeseen complications can occur. The party acknowledges and agrees that this authorization form may be executed by electronic signature, which shall be considered as an original signature for all purposes and shall have the same force and effect as an original signature. Signature * signature keyboard Clear Today's Date * Captcha Submit If you are human, leave this field blank.
