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Surgery Consent Form

Owner's Full Name:(Required)

Owner's Address:

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Owner's Phone Number:(Required)

Owner's Email:(Required)

Pet's Name:(Required)

Pet's Species:(Required)

Canine (Dog)

Feline (Cat)

Pet's Sex:(Required)

Pet's Breed:(Required)

Pet's Date of Birth or Approx. Age:(Required)

Pre-Surgical Bloodwork

Your pet will be undergoing general anesthesia for a surgical procedure today. In order to recognize any underlying abnormalities your pet may have, we recommend having a pre-surgical blood profile run on your animal. This consists of a CBC, which will check blood cells, and an ALT, ALKP, CREA, GLU, TP and BUN, which will check blood glucose, kidney and liver enzymes.

These blood tests will help us to assess the health status of your pet more completely and determine if there are any additional precautions we need to take before the procedure. We do require a blood profile for pets over 5 years old. We hope you understand the need for these important tests and the benefits they can have for your pet’s health.

Please select:(Required)

I DO wish to have the pre-surgical blood profile done on my pet.

I DO NOT wish to have the pre-surgical blood profile done on my pet.

I am unsure and would like to speak to a veterinarian before deciding.

By signing below, you give North Texas Veterinary Clinic and their veterinarians the right to put your pet under anesthesia for a surgical procedure. You also acknowledge and agree that all information noted on this form is true and correct.

Owner's Name:(Required)

Print Your Full Name

Owner's Signature(Required)

Sign Your Full Name

Today's Date:(Required)

Date your pet will have the surgical procedure performed:(Required)

Emergency Contact Number:(Required)

Additional comments/notes:

Clinic Use Only

Scheduled Procedure(s):___________________

Mass Removal? Confirm and note location:_______________________

Send out biopsy?_____________________

Spay? If applicable, when was patient’s last heat cycle?________________________________

Last time patient ate or drank anything:_____________________________

Any history of drug allergies or anesthetic complications?_________________

Current medication?____________________

Last time patient received any medications:_____________________

Any additional services needed today (AGE, TNT, MC)?__________________________

Afternoon availability for discharge appt:______________________

Pet’s current weight:________________________

E-collar needed?____________________

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