General Surgery Form - Florence Animal Hospital - Florence and Hartsville Animal Hospital

General Surgery Form - Florence Animal Hospital

Consent Form for General Surgery

Date(Required)

Owner Name(Required)

First Last

Patient Name(Required)

Primary Phone(Required)

Secondary Phone

Address

Street Address City State ZIP / Postal Code

As the owner or agent of the above animal, I hereby give my consent to Florence Animal Hospital to perform the following procedure(s):

I understand that during the performance of this procedure, unforeseen conditions may be revealed that necessitate an extension or variance in the procedure(s) set forth above. I understand that Florence Animal Hospital will attempt to contact me one time at each of the number(s) listed above. If there is no response, I consent to any procedures the veterinarians deem medically necessary.

I expect Florence Animal Hospital to use reasonable care and judgment in performing the procedure(s). The nature of the procedure and risks involved have been explained to me and I realize results cannot be guaranteed. I am also aware that unforeseen events resulting from the procedure(s) will not relieve me from any obligation to all reasonable costs incurred regarding the animal.

Would you like a microchip ($68) placed while under anesthesia?(Required)

Yes

Pregnancy Stage Acknowledgement (Females Only)

I, the undersigned owner (or authorized agent), hereby authorize Florence Animal Hospital and its staff to perform a spay (ovariohysterectomy) with pregnancy termination (spay-abort) on the above-named animal.

I, the undersigned owner (or authorized agent), hereby DO NOT authorize Florence Animal Hospital and its staff to perform a spay (ovariohysterectomy) with pregnancy termination (spay-abort) on the above-named animal.

In the event of an emergency:(Required)

CPR: If necessary, I wish for the veterinarian to perform CPR on my pet and to initiate any other necessary life saving measures while trying to contact me. I agree to be responsible for the costs of such measures and understand that these measures may lead to costs greater than the estimate given.

DNR: I do not wish for the veterinarian to perform CPR on my pet in the event of an emergency.

The staff of Florence Animal Hospital takes the well-being of your pet very seriously. Despite advances in anesthetic and surgical procedures, complications can arise due to pre-existing conditions. To avoid these problems, we require a minimum database pre-anesthetic laboratory test.

For all patients under the age of six and apparently healthy, a basic blood chemistry panel and a complete blood count will be performed at the cost of $83.00.
For patients over the age of six and those with other potential underlying issues, a comprehensive blood panel and a complete blood count will be performed at the cost of $150.00.
An IV catheter placement is required for all anesthetized/surgical patients regardless of age. This placement allows the veterinary staff to administer fluids to maintain hydration and blood pressure. It also provides quick access to veins in case of an emergency situation. A small patch of fur will be shaved on either the forearm or the back legs in order to do so. This is not optional; it is required protocol here at Florence Animal Hospital.
The doctors of Florence Animal Hospital will prescribe appropriate pain medication for surgical procedures.

ALL ANIMALS MUST BE CURRENT ON THEIR VACCINATIONS AND MUST BE FREE OF EXTERNAL PARASITES. ANY ANIMAL FOUND TO HAVE FLEAS/TICKS WILL BE TREATED AT THE OWNER’S EXPENSE.

Signature(Required)