Online Form

Surgery Consent Form

We are thrilled to have you and your pet with us. To help us better understand how to provide the best care for your companion, please carefully complete the following questionnaire for your pet’s upcoming appointment.

Get Started

Surgery Consent Form

Name *

First

Last

Email *

Patient Name *

Procedure *

Doctor: Koger

Has your pet had any medication recently? *

Does your pet have any allergies/reactions to anything? *

It is our goal to provide the highest level of care to all of our patients. Throughout their entire procedure, your pet will be fully monitored by our licensed veterinary medical team. Monitoring includes, but is not limited to, EKG, pulse oximetry (Oxygen levels), blood pressure, temperature, and capnography (CO2 levels).

Blood Testing

With any procedure requiring anesthesia, risk is involved. To reduce risk, we require pre-anesthetic blood screening for all patients. This is required regardless of the patient's age or health. This blood screening (CBC and Chemistry) evaluates internal organs, looking for problems that will not be seen on a physical exam. The CBC looks for hidden infections, anemia and any indication of clotting issues. The Chemistry looks at kidney and liver function to make sure they are functioning properly. We have 2 levels of blood work profiles. The profile that is performed on your pet will be done at the discretion of the veterinarian. The cost range is $125 - $160. *prices subject to change without notice. *

I have read, understand, and approve the above information.
My pet has already had bloodwork

Microchip Implantation

A Home Again® Microchip can be implanted under the skin while Winston is under anesthesia. Microchips are utilized as a tool to use if your pet ever goes missing. The microchip procedure is a safe and simple way to permanently identify your pet and unlike a collar and tags, the microchip can not simply be removed. The cost of the microchip, which includes registration, is $68.00. *prices are subject to change without notice* *

My pet already has a microchip.
Yes, I would like a microchip implanted during my pet’s surgical procedure.
No, I decline placement of a microchip at this time.

Pain Management

Your pet will receive pain medication during their surgery to ensure a comfortable recovery. If needed, additional pain medication will be dispensed after surgery to ensure comfortability at home. This will be determined by the veterinarian after the procedure. *

I have read, understand, and approve the above information.

Dental Extractions

The licensed veterinary team will assess all of your pet’s teeth. If any teeth are severely mobile, have bone loss or root exposure, or are fractured in such a way to include the pulp, or nerve, they will be extracted at the doctor’s discretion. We do not currently have the ability to perform dental radiographs, so the assessment will be made without the aid of x-rays. *

I understand there is a possibility extractions may be necessary during my pet’s dental procedure.
My pet is not having a dental procedure today

Biopsy of Mass(es) Removed

We recommend that masses removed during surgery be sent to the laboratory for microscopic evaluation. This information is vital to determine the type of mass, grade of the mass and curative factors of the surgical procedure. This is important in determining if the mass is benign or malignant, if there is a chance of recurrence and the long term health of your pet. The cost of the biopsy depends on size, location, and how many masses are being submitted. The range is $250.00-$450.00. *Please note that prices are subject to change without notice. *

Yes, I would like the mass (es) submitted to the laboratory.
No, I decline having the mass (es) submitted to the laboratory.
I would like to discuss with the veterinarian after removal of the mass (es).
My pet is not having a mass removal today

I certify that I am the legal owner *

I certify that I am the legal owner or agent of the above described animal and do hereby consent and authorize the Doctors and Staff of North Suffolk Animal Clinic to perform the above listed surgical, diagnostic, and treatment procedure(s) on my pet. The nature of the above listed procedure(s) has been described to my satisfaction. I consent to the administration of any sedatives, anesthetics, pain relievers, or other medications deemed necessary by the attending veterinarian.

I understand that no guarantee or assurance *

I understand that no guarantee or assurance has been made regarding the results of the treatment procedure, anesthesia, or surgery performed. I acknowledge that any surgical procedure, treatment, or anesthetic event, even performed on a healthy animal, carries a certain degree of risk and possibility of complications. I accept these risks and direct the Doctors and staff of North Suffolk Animal Clinic to perform said procedure(s). I understand that the Doctors and staff will make every reasonable attempt to safely and proficiently care for my pet. I also understand that unknown conditions may require additional treatments, procedures, diagnostic tests, or surgery to be performed on my pet. I understand that every reasonable effort will be made to contact me, but until I can be contacted, I authorize the Doctors and staff of North Suffolk Animal Clinic to perform any reasonable treatment or procedure for my pet deemed necessary by the attending Veterinarian.

The Doctors and staff of North Suffolk Animal Clinic will not be held responsible *

The Doctors and staff of North Suffolk Animal Clinic will not be held responsible or liable in the absence of gross negligence if my pet should injure itself, refuse food, soil itself, become ill, or expire while in the clinic.

I further realize that I am responsible for payment *

I further realize that I am responsible for payment for the above procedure(s) and treatment(s) in full at the time the animal is discharged. If I neglect to pick up the animal within five (5) days of written notice, to the above address, that it is ready for release, you may assume that the pet is abandoned. North Suffolk Animal Clinic is then authorized to make decisions about the animal as deemed necessary. Abandonment does not release me of my obligation for this bill. I further agree that in the case of nonpayment, a finance charge will be charged and I will be held responsible for any collection fees.

Signature *

Clear Signature

*This person must be over the age of 18 years and must be an authorized person on this account.

Contact phone # *

* Someone must will be available via phone between the hours of 8:30 am and 5:30 pm and be an authorized person on this account

Date *

Surgery Consent Form

Surgery Consent Form

Blood Testing

Microchip Implantation

Pain Management

Dental Extractions

Biopsy of Mass(es) Removed

Ready for a visit?

Have a Question?

Contact Us

Location

Hours