Procedure Consent Form "*" indicates required fields Name of Pet Client Sex Weight Procedure Required Vaccines and Exam for Surgical and Sedated Procedures Canine: Rabies, Distemper, Parvovirus Feline: Rabies, Distemper I am the owner or authorized agent for the owner of the animal described above, and I have the authority to execute this consent. My signature below certifies that I am over eighteen years of age. I understand that if I cannot provide records of my pet’s current vaccines, for my pet’s safety Prairie View Animal Hospital will provide my pet with updated vaccines and/or an exam prior to any procedure. I understand that in order for my pet to have a surgical or sedated procedure done, they must have a current physical exam (within the last 12 months), current bloodwork (within the last 2 months), and have been healthy since the blood test was performed. If there is no current bloodwork on file, I understand that Prairie View Animal Hospital will, for my pet’s safety, obtain current bloodwork. In-house pre-surgical bloodwork is performed to ensure that my pet is healthy enough to be sedated and/or placed under general gas anesthesia. If your pet is less than eight (8) years of age, you may opt for a minor or major blood chemistry panel. If your pet is older than eight (8) years of age, a major blood chemistry panel is required. I understand that a small area on my pet’s leg(s) will be shaved for the purpose of placing an intravenous catheter and/or monitoring blood pressure. Pending the procedure named above, additional areas may be shaved on my pet as well. I have been encouraged and given the opportunity to discuss any questions and/or concerns I have regarding my pet’s medical care and my questions and/or concerns have been addressed to my satisfaction. I understand and accept that my financial obligations remain regardless of the outcome. I have had likely fees explained to me and accept and assume full and total responsibility for any and all services rendered at Prairie View Animal Hospital. Additional medications may be provided at an additional cost for the safety and comfort of my pet. Authorized Agent Initials In the event of an emergency, is it your desire that our doctor and staff perform CPR on your pet? Yes No CPR is a life-saving procedure that uses medications, artificial breathing, and chest compressions if a pet stops breathing on their own and/or their heart stops beating. If we cannot reach you by phone, do you authorize additional services to be performed or additional medications to be administered while your pet is in our care if the doctor deems it necessary? Yes No Non-Emergency Contact Information:How would you like us to contact you after the procedure is complete? Call Text E-mail Phone (for calling)Phone (for texting)Email Emergency Contact Name and Number:Please provide information for someone authorized to make informed decisions about your pet if you are unreachable.NameNumberI authorize the use of sedatives and/or anesthetics as you deem advisable in the performance of such surgical, diagnostic, and therapeutic procedures. I understand that the administration of any sedative and/or anesthetic agent carries a small but realistic possibility of side effects, which may include death. I recognize the risks and complications that are involved. I acknowledge that no guarantee or assurance has been made as to the outcome of this procedure. I understand and accept the potential risks associated with the above procedures of my pet and have been given the chance to ask any questions I may have. I give Prairie View Animal Hospital authorization to perform surgical or sedated procedure(s) on my pet. Printed Name* Date* MM slash DD slash YYYY Signature*ADDITIONAL OPTIONS: (prices subject to change)Blood Work Minor Presurgical Panel ($76.65) Major Presurgical Panel ($88.86) BW Done On Tooth Extractions ($25.86 to $86.96) Yes No N/A Histopathology: Tissue specimen sent to lab for analysis ($146.83) Yes No N/A E-Collar or Recovery Collar: Worn to prevent licking an incision site ($6.44 to $33.12) Yes No N/A Send Home Sedative: To provide sedation during recovery (Varies by Size) Yes No N/A Surgical Suit: Alternative to traditional e-collar ($24.04 to $38.58) Yes No N/A Microchip: Implantation of a small chip underneath a pet’s skin near the shoulder region which serves as a permanent form of identification ($56.87) Yes No N/A Anal Gland Expression ($30.00) Yes No N/A Toe Nail Trim ($16.00) Yes No N/A Mass Removals and/or Area(s) in Question Please indicate where the lesion(s) and or areas in question are on the appropriate diagram below: File(Upload pet's body map with markings here)Max. file size: 256 MB.Additional InformationPet’s last meal timeAny prior drug/medication or vaccine reaction(s)?Last heat cycle (if applicable)Current MedicationsPersonal Items at IntakeEmailThis field is for validation purposes and should be left unchanged.
