Canine Consent Form

Pet Owner Name

First Last

Pet Name

First Last

Phone

I am the owner or agent for the owner of the above described animal and have the authority to execute this consent.(Required)

I understand that during the performance of the foregoing procedure(s) or operation(s), unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure(s) or operation(s) or different procedure(s) or operation(s) than those set forth above. Therefore I hereby consent to and authorize the performance of such procedure(s) or operation(s) as are necessary and desirable in the exercise of the veterinarian's professional judgment.

I also authorize the use of appropriate anesthetics and other medications and I understand that hospital support personnel will be employed as deemed necessary by the veterinarian. I have also been informed that there are risks associated with the use of any medication.

I have been advised as to the nature of the procedure(s) or operation(s) and risks involved. I realize results cannot be guaranteed.

As part of our normal surgical procedure, a catheter will be placed and IV fluids will be given during surgery.

I hereby consent and authorize the performance of the following procedure(s) or operation(s).

PRE-ANESTHETIC BLOOD TESTING(Required)

Before putting your pet under anesthesia a physical exam will be performed. As part of the pre-surgical examination we offer a pre-anesthetic blood panel. These tests are similar to those your own physician would run if you were to under go anesthesia. These tests may be useful in diagnosing liver/ kidney disease, diabetes or other conditions that could complicate a surgical procedure.

Yes I would like to have pre-anesthetic blood work done ($80.00)

No I decline blood work

PAIN MANAGEMENT(Required)

Fee varies by weight of patient

Pain medication with surgery and sent home

Pain medication with surgery only

No I decline pain medication

HEARTWORM TEST(Required)

Fee varies by weight of patient

Yes I would like my pet Heartworm tested ($36.00)

No I decline Heartworm testing.

If negative, would you like Heartworm medication sent home(test is good for 1 month without medication)

Yes

911 PetChip & Lifetime Registration(Required)

Fee varies by weight of patient

Yes I would like my pet micro-chipped ($32.00)

No I decline the microchip.

DENTAL CLEANING/EXTRACTION(Required)

If your pet is scheduled for a dental cleaning, a licensed technician or veterinarian may perform the procedure. Extractions may be a necessary part of the dental procedure. If you mark yes for extraction a veterinarian will extract the necessary teeth. Diseased teeth can be a source for re-infection.

Yes you may extract teeth as necessary(Fee varies by difficulty)

No I decline any extractions

GROWTH REMOVAL(HISTOPATH)(Required)

If we are removing a growth would you like it sent in the pathologist for identification.

Yes I would like the growth sent in ($300.00-1 site)

Do not send in.

Authorization(Required)

I have read and understand this authorization and consent and am aware that payment for today's services is required. I also understand that Lahontan Valley Veterinary Clinic is not staffed 24 hours a day and my pet will not have overnight medical supervision.

Best Contact Phone #

May we text you at this number for an update on your pet?

Yes

Last Food/Water

Medication

Antibiotics, Asprin, etc.

Last Given

I will allow an intern to perform the above procedure/surgery under the direct guidance of one of our veterinarians.(Required)

Yes

E-collar ($10.00-$30.00)

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