Pediatric Surgery Authorization & Consent Form Owner's Name* First Last Owner’s initials*(indicate consent to named procedure for above pet)Pre-Surgical Information (IMPORTANT- Please initial that you have read each line and note ALL medications):Patient has not eaten anything after 9 pm the night before operation.*(Please initial)Is your pet on ANY medications?*(Please initial)Is your pet on ANY medications?*YesNoPlease list ALL medications*Drug NameDosageLast dose given NOTE: If fleas and/or ticks are seen, a flea/tick product will be applied or given by mouth.Does your pet have any known allergies?*(Please initial)Does your pet have any known allergies?YesNoPlease explain.*ALL services below will be at additional cost not covered in “Pediatric Spay/Neuter” price.Please INITIAL to give your consent to each recommendation below. These items will be at an additional cost.I understand that if my pet is in-heat, pregnant or cryptorchid, that I am responsible for additional cost of $30-120.(Please initial)I would like for my pet to have IV fluids administered during the surgery. $21.90 for IV fluids(Please initial)I hereby authorize and direct the veterinarian to perform CPR (cardiopulmonary resuscitation) and other life saving measures in case of an emergency.(Please initial)I hereby authorize the veterinarian to extract any teeth deemed medically necessary, including retained deciduous ("baby") teeth. Cost: $20-40 per tooth(Please initial)I would like my pet to be protected with a Microchip. This microchip is placed under your pet’s skin with a hypodermic needle for permanent identification. Cost: $55.00(Please initial)I acknowledge that the veterinarian/staff member has discussed the importance and benefits of performing pre-anesthetic bloodwork to aid in designing the appropriate anesthetic protocol for my pet. (Please choose one choice below):*YES, I do want my pet to have pre-surgical bloodwork. The cost is $97.00.NO, I do not want my pet to have pre-surgical bloodwork.I understand the above anesthetic and surgical, diagnostic or therapeutic procedures may involve risk of complications, injury or even death, from both known and unknown causes and no warranty or guarantee has been either expressed or implied as to result or cure. Furthermore, I authorize the hospital staff in an emergency situation, to follow through with such procedures as are necessary for the well being of my pet on a continuing basis until further communication with me. I agree to assume financial responsibility for all routine and emergency services rendered.Your signature below constitutes your acknowledgement that (i) you have read and agreed to the above, (ii) the procedure(s) have been explained to your satisfaction and that you have all the information that you desire, (iii) you have had the chance to ask questions, and (iv) you authorize and consent to the performance of the procedure(s) and to the administration of anesthesia.Owner Signature*Phone number(s) with area code where you can be reached today*NOTE: It is very important that we are able to reach you at all times while your pet is in the clinic for a surgical procedure.
