Surgical Consent Form - Clovercroft Veterinary Hospital

CLICK HERE to Print the Surgery Consent Form OR fill out and submit the electronic version below

Pet Name*
Pet Owner/Authorizing Agent Name*
Email*
Phone number at which I can be reached immediately and at all times today.*
I am the owner or agent for the above described pet and have the authority to execute this consent. I hereby consent and authorize the performance of the following procedure(s):
I understand that during the performance of the foregoing procedure(s), unforeseen conditions may be revealed that necessitate the extension of the procedure(s) or different procedure(s) than those set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) as are necessary and desirable in the exercise of the veterinarian’s professional judgment.

I also authorize the use of appropriate anesthetics, analgesics, fluid therapy and other medications, and I understand that the judgment of hospital support personnel will be employed as deemed necessary by the veterinarian (e.g. to control post-operative pain).

I have been advised as to the nature of the procedure(s) and the risks involved. I realize that results cannot be guaranteed. I have read and understand this authorization and consent.
PRE-ANESTHETIC BLOOD TESTING
Before placing your pet under anesthesia we will perform a physical examination. However, many conditions, including disorders of the liver, kidneys or blood, are not detected unless blood testing is performed. Such tests are especially important before any kind of surgery. For these reasons, we highly recommend blood screening before such procedures.
Please choose one of the following:
- Yes, I want my pet to have a BASIC pre-anesthetic blood screen for a cost of $57.00
- Yes, I want my pet to have a FULL pre-anesthetic/geriatric blood screen for a cost of $148.17 (recommended for pets 7 years or older, chronic medical conditions, etc.)
- No, I do not want my pet to have a preanesthetic blood screen
MICROCHIPPING
Microchips are small identification chips that can be implanted under your pet’s skin. Each chip has a unique identification number that is connected to your information. This can be done painlessly for your pet while he/she is under anesthesia today.
Please choose one of the following:
- Yes, I would like my pet to receive a HOMEAGAIN microchip at a cost of $54.39. This includes the microchip, one time registration fee & 1 year membership.
- No, I do not authorize my pet to be microchipped today
- My pet is already microchipped
PAYMENT POLICY
I understand payment is expected in full at the time services are provided and I assume full financial responsibility for all procedures. I agree to make full payment for all services and products using either cash, check, debit card, Visa, MasterCard, Amex and/or Discover credit cards.
If you accept the terms of our payment policy, select "I Agree" below*
- I Agree
FOR IN-OFFICE USE ONLY: Signature Field
Name
This field is for validation purposes and should be left unchanged.

PRE-ANESTHETIC BLOOD TESTING

MICROCHIPPING

PAYMENT POLICY