Princeton Surgery/Procedure Consent

GENERAL

Client’s full name

Chart #

Patient

Age

Date

How can you be reached today?

Home Phone

Work Phone

Cell Phone

Surgery to be performed today

Weight

Bath?

Yes No

Special Instructions:

Dental w/ Polishing Oravet Application / Home Kit / Chews Post Surgical Therapeutic Laser X-Ray

Notes:

H/O Seizures

Yes No

Histo/Biopsy

Yes No

Laser (optional advanced technique to reduce bleeding and swelling, resulting in a quicker recovery)

Yes No

Examine and Treat

Yes No

Post-Op Pain Prevention Options:

Post surgery pain injection Medication to go home

Initials

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

Initials

Canine:

Feline:

Feline Distemper Vaccine Feline Leukemia Vaccine FELV/FIV/Heartworm Test

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 adequate 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. The estimated cost for this lab work is only $65.00–70.00. 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 PLLC permission to provide the above-indicated service(s) for my pet. Please complete the recommended blood work prior to surgery on my pet. If abnormalities are found, please contact me at this phone number:

Phone

Signature:

I have elected to REFUSE the recommended pre-anesthetic blood tests at this time and request that you proceed with anesthesia.

Signature:

Animal Care Center

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Princeton, WV

Pearisburg, VA

@ 2025 Animal Care Center

Princeton, WV

Pearisburg, VA

Princeton, WV

Pearisburg, VA