Surgical Consent Form

Client *

Patient *

Email *

Date *

Pre-Anesthetic Bloodwork/Other Procedures *

Yes, I want my pet to have a pre-anesthetic blood screen/other procedure
No, I do not want my pet to have a blood test or other procedures. I acknowledge that there may be concealed health risks to my pet and will not hold this hospital responsible for any anesthetic complications. I understand the surgery or treatment contemplated is

What procedure(s)? *

$110.00 (Mini Profile)
$185 (CBC, Chemistry, Electrolytes)
$50.00 FeLV/FIV/Heartworm test
$50.00 Heartworm Test (4DX Plus)
$60 IV Catheter Placement
Vaccine Update (ask cost)
Post-Surgical Pain Medications (ask cost)
Therapy Laser (ask cost)
$7.50 Post-Operative Laser Treatment

I understand the surgery or treatment contemplated is *

LASER

I understand that laser surgery is an option for my pet, and I have been advised of the advantages this option will offer. *

Yes, I want my pet to have laser surgery. The cost is $40.00 plus the cost of surgery.
No, I do not want my pet to have laser surgery.

Dental Extractions/Procedures

Please check one of the following:

Perform any necessary procedures and extractions at this time
Perform only the requested dental procedures at this time. Call me after the dental exam and provide an estimate of any additional procedures. DO NOT proceed without authorization.
Digital Radiographs

Digital Radiographs

One View $35
Full Mouth $140.00
Decline Radiograph

Elective Procedures

Please list any additional procedures you would like to be performed: (anal glands, microchip, fecal exam, check ears, etc)

As the owner, or agent, of the pet above, I certify that I am over the age of 18 and I authorize the staff of this hospital to perform the procedure(s) listed above, as well as those deemed necessary to treat life-threatening emergencies. As with all anesthetic, treatment, and/or surgical procedures, I understand there are risks inherent in these services. I acknowledge that staff members at this practice have explained the procedures to me, answered questions to my satisfaction and cannot be held responsible for any unforeseeable results. Further, I understand that I am financially responsible for all costs incurred during this surgery, treatment, and hospitalization and that I will leave a deposit and pay any remaining costs in full upon completion of treatment.

I have read and understand.

Signature of owner or responsible party

How would you like us to notify you when your pet is finished with surgery/procedure?

Text message
Phone call

Text message to *

Phone to *

File Upload *

Click or drag a file to this area to upload.

Welcome to Tekonsha Animal Hospital!

Surgical Consent Form

Submit Your Completed Form Below

LASER

Dental Extractions/Procedures

Elective Procedures