SURGERY CONSENT FORM

PLEASE READ CAREFULLY BEFORE SIGNING

Date:

*Owner's Name:

*Phone Number:

*Patient's Name:

Procedure Scheduled:

Dr:

During this procedure, your pet will receive the following:

A full physical examination prior to the anesthesia.
A comprehensive pre-surgical blood profile to ensure proper function to properly handle anesthesia.
An intravenous catheter for venous access to administer fluids which helps assess depth of anesthesia and access in case of emergency.
Monitoring by technicians using a pulse oximeter.
Pain management where appropriate.

The nature of the procedure has been explained to me and no guarantee has been made as to results or cure. I understand that there is a risk involved in these procedures, including that of anesthesia. I have read and accept the above conditions of this hospital admission statement.

*E-Signature:

*Phone number I can be reached immediately today:

*Email where I can receive correspondence today:

DENTAL PROCEDURE CONSENT FORM

*Date

*Name

*Contact Number

*Patient's Name

Dr:

During this procedure, your pet will receive the following:

A full physical examination prior to the anesthesia.
A comprehensive pre-surgical blood profile to ensure proper organ function to properly handle anesthesia.
An intravenous catheter for venous access to administer fluids which helps assess the depth of anesthesia and access in case of emergency.
Monitoring by technicians using a pulse oximeter.
A tooth-by-tooth oral examination once your pet has been anesthetized.
Ultrasonic scaling, hand-scaling, and polishing.
Pain management where appropriate.

Full mouth dental radiographs are advised once a year.

Please choose one:

I accept comprehensive pre-surgical blood profile.I decline comprehensive pre-surgical blood profile.

COST: $106.33

Please choose one:

I accept full mouth dental radiographs.I decline full mouth dental radiographs.

COST: $82.19

Please choose one:

I accept placement of a microchip for my pet.I decline placement of a microchip for my pet.MY PET already has a microchip.

COST: $64.99

I understand that once my pet has been anesthetized and the oral cavity has been fully examined, finding additional pathology is not unusual.

The nature of the procedure has been explained to me and no guarantee has been made as to results or cure. I understand that there is a risk involved in these procedures, including that of anesthesia. I have read and accept the above conditions of this hospital admission statement.

Signed by:

*Client Name/Agent:

*Phone Number I can be reached immediately today:

*Email where I can receive correnpondence today:

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New Client Registration Form

REGISTRATION

PET INFORMATION

AUTHORIZATION / CREDIT POLICY

SURGERY CONSENT FORM

DENTAL PROCEDURE CONSENT FORM

Helpful Articles

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Request Appointment

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Contact Information

Hoegemeyer Animal Clinic Hours

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