Pearisburg Surgery/Procedure Consent

GENERAL

Date:

Is your pet feeling well today?

Yes No

Weight:

Emergency Contact:

H/O Seizures:

Yes No

Was Food Withheld Overnight?

Yes No

Pre-Procedure Exam Needed: ( new patients only)

Yes No

Medications:

Yes No

If yes to medications, list and time when dose was given:

Surgery to be performed:

Laser:

Yes No

Histo/Biopsy to be performed:

Yes No

Dental:

Oravet Application Home Kit Oravet Chews Decline

Vaccines & Screening:

Heartworm Prevention:

Yes No

If yes, which product and how many doses?

Flea/Tick Prevention:

Yes No

If yes, which product and how many doses?

Other Med Refills:

Yes No

If yes, please list the medications.

For the protection of your pet and others, we require all vaccines to be current and for your pet to be flea-free. Any necessary flea treatment will be at your expense

I Accept

Microchip:

Yes No

Our microchips have the ability to be scanned to take your pets temperature which reduces the need for rectal temperature checks.

Do you need to purchase an E-Collar (cone) for your pet?

Yes No

Post-Op Pain Prevention Options:

Post Pain Injection Medication to go home For Canine - Pills or Liquid preferred? Both Post Pain Injection and Medication to go home

Please Read Carefully and Sign:

Your pet is scheduled for anesthesia and /or surgery. Before putting your pet under anesthesia, we recommend that a pre-anesthetic blood profile be performed to maximize patient safety. Among the reasons for this test are to assure proper kidney and liver function, to assure adequate oxygen carrying capacity and ability to fight infection, to assure platelets for blood clotting, and to identify early warning signs of major blood and organ dysfunction. Results will be available immediately to review before anesthesia. I am aware of the risks involved in the administering of anesthesia and the performance of surgery on this animal. I hereby give Animal Care Center of Pearisburg permission to provide the above-indicated service(s) for my pet. Please complete the recommended bloodwork prior to surgery on my pet. If abnormalities are found, please contact me at this phone number:

Phone

Signature:

I have elected to REFUSE or my pet has already had the recommended pre-anesthetic blood tests at this time and request that you proceed with anesthesia.

Signature:

Any questions or concerns for Surgeon?

Animal Care Center of Pearisburg Surgical Consent Form

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Princeton, WV

Pearisburg, VA

@ 2025 Animal Care Center

Princeton, WV

Pearisburg, VA

Princeton, WV

Pearisburg, VA