Client's Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Patient's Name *

Species *

Breed *

Sex *

Color *

Weight *

Anesthetic and surgical procedure(s) to be performed: *

Possible Additional Procedures:

Vaccinations:

DAPP

Yes
No
Current

Bordetella

Yes
No
Current

Rattlesnake

Yes
No
Current

Rabies

Yes
No
Current

Fecal

Yes
No
Current

Heartworm Test

Yes
No
Current

Microchip

Yes
No
Already have one

Sending Mass out for testing:

Yes
No
N/A

If we are removing a mass or taking a sample, we recommend sending sample to Texas Veterinary Pathology Associates to have testing performed. Pathologists are trained to evaluate many different types of tissue. They use powerful microscopes to evaluate the cells within each tissue sample. This multilayered team evaluation helps ensure that patients receive a detailed and accurate diagnosis. Please contact one of our technicians for the cost of this test.

Pre-Surgical Bloodwork:

Yes
No
Already ran

We offer and recommend pre-anesthetic blood testing to check for underlying or congenital conditions that may compromise the patient under anesthesia. This testing is required for patients over 6 (six) years of age or at the discretion of the doctor. The cost for this testing is addition to the above procedure(s) is $89.00.

Plaque Prevention Gel:

Yes
No

To help prevent gingivitis and tooth loss, we can apply a sealant to your pet's teeth that will significantly reduce the rate of tartar build up, bad breath, and maintain the work done today. The additional cost is $34.08.

Post-Operative pain management:

Your pet's comfort level is very important to us and it is well known that pain/inflammation reduction speeds up the healing process. Surgical sites are treated with a therapeutic laser, patients are given a long acting pain injection at surgery time and females are sent home with additional oral pain relievers. This additional cost is $24-$36. I, the undersigned owner or agent of the pet identified above, authorize the staff of Chimney Rock Animal Hospital to perform the above procedure(s). I understand that some risks always exist with anesthesia and/ or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated.

I understand that the attending veterinarian will make every effort to contact me regarding treatment in thecase of unforeseen emergencies. If unable to contact me, the staff may or may not have my permission toproceed with life sustaining procedures.

I give my permission (yes)
I do not give my permission (no)

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow up radiographs, re-check physical exams and additional surgery due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions. A complete physical exam will be performed on your pet prior to the surgical procedure if it has been longer than 30 days since the last exam. However, this may not identify all systemic or metabolic problems. For this reason, your pet will have a pre-anesthetic blood panel to evaluate major organ functions prior to anesthesia. I have read and fully understand the terms and conditions set forth above.

Signature *

Clear Signature

Date *

Phone number(s) at which owner can be reached today or tomorrow:

Chimney Rock Animal Hospital

Canine Surgical Consent Form

Online Form