Consent To Perform Spay/Neuter

Client Information

Full Name*

Address*

City*

State*

Postal Code*

Phone Number*

Patient Information

Name*

Species*

Sex*

Date of Birth*

Breed*

Personal Belongings

Was your pet fasted overnight?

Has your pet experienced any abnormal behavior recently? (ie: lethargic, vomiting, diarrhea, change in appetite, scooting, change in urination)

Is your pet current with all of their required vaccinations?

Does your pet have any food allergiesNoYes

Food allergies*

Has your pet had any previous vaccine or medication reactions?NoYes

Previous vaccine or medication reactions*

When was your pet last in heat (females only)?

Current Medications NoYes

Medication

Dose

Time last given

Medication

Dose

Time last given

PREANESTHETIC BLOOD TESTING: Mandatory for all animals over 6 years of age

Elective Surgery(under 6 yrs of age) Mini blood chemistry, electrolytes and CBC testing to assess liver, kidney function, anemia, infection and dehydration in your pet for safe anesthetic protocols.

$185.00

Elective Surgery(over 6 yrs of age) Full Blood chemistry, electrolytes and CBC testing to assess liver, kidney function, anemia, infection, dehydration and electrolyte imbalance in Senior pets for safe anesthetic protocols

$210.00

Heartworm/Lyme Test add-on Blood test for heartworm, lyme disease, anaplasma and ehrlichia as routinely done every spring. *As an addition to the above bloodwork only*

$51.00

Decline

INTRAVENOUS FLUID THERAPY: Mandatory for all dental procedures, brachycephalic breeds, dogs under 4 kg, cats
under 2 kg, and animals over 6 years of age

To allow immediate access to a vien in case emergency drugs need to be administered. To keep your pet hydrated before, during and after surgery. This also helps the body to flush out the anesthetic drugs used during surgery.

$83.00

Decline

TATTOO (free)*AcceptDecline

MICROCHIP($79)*AcceptDecline

FLUORIDE TREATMENT ($26-32)*AcceptDecline *Free w/ dental cleaning*

PROTECTIVE APPAREL (must pick one)*E-Collar ($12-42)Medical Shirt (Dogs Only) ($52-63)

With a routine spay or neuter there are other medical conditions that we may come across during our pre-surgical exam. If any of the following are found we will attempt to contact you prior to beginning of surgery:

In the event I cannot be reached, Sage Creek Animal Hospital has permission to proceed with medical care for:

CPR & lifesaving measures including IV fluids, medication, intubation, ventilation, & more:*AcceptDecline

Additional services that will preserve or enhance my pet’s health (i.e. dental extractions):*AcceptDecline

I hereby authorize and direct the veterinary staff of the Sage Creek Animal Hospital to perform the above-mentioned procedure(s)and additional diagnostic and /or treatments as deemed advisable or necessary for my pet. The nature of the procedure(s) has been fully explained and I understand them.

I also certify that no guarantees or assurances have been made regarding the results that may be obtained. I understand that some risk of injury or death always exists with anesthesia and/or surgery, and I am encouraged to discuss any concerns I have about those risks with my veterinarian before the procedure is initiated.

Furthermore, I accept the financial responsibilities for all charges incurred to be settled at the time of discharge unless otherwise arranged with the hospital. I understand that any written or quoted estimates are an approximation and the costs may be more or less than the amounts.

With my signature I hereby certify that I have read and fully understand the above statements.

Sage Creek Animal Hospital would like your permission to use photographs and/or videos taken of your pet during their visit with us. These photographs and/or videos are for Sage Creek Animal Hospital to disclose during educational activities, at its events and in its promotional material, in print and electronic format, including on the Internet via the Sage Creek Animal Hospital website or other social media. *AcceptDecline

Sage Creek Animal Hospital reserves the right ensure all pets are sent home with an appropriate restraint system such as a carrier or a leash. In the case that the owner cannot provide a carrier or leash, Sage Creek Animal Hospital will supply one for a fee which may or may not be refundable.

Primary Contact Name & Number today*

Secondary Contact Name & Number today

Date*

Signature(client signature)*

Consent To Perform Spay/Neuter