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Surgery Consent Form

Owner's Name:*
First Last
Pet's Name:*
Email*
Surgery to be performed:*
Please answer the following questions about your pet.
Last time your pet ate*

: Hours

Minutes

AM/PM
Recent injury, illness or surgery?*
- Yes
- No
What and when?
Current medications?*
- Yes
- No
Please list and specify when last dose was given.
Any known allergies?*
- Yes
- No
What?
Any history of seizures?*
- Yes
- No
Felv/FIV/Heartworm status?*
- Positive +
- Negative -
- Unknown
Can we test today?
- Yes
- No
Date of last blood work:
MM slash DD slash YYYY
Do you want pre-op blood work performed?*
Less than 7 yrs old Chem 10/CBC $97
7 yrs and older Chem 17/CBC $153
- Yes
- No
Would you like vaccines updated?*
- Yes
- No
Would you like your pet microchipped?*
Cost: $46
- Yes
- No
If a dental operation is going to be performed, do you authorize the doctor to make any necessary tooth extractions?*
- Yes
- No
INFORMING: We will place a catheter for your pet's safety.
Anesthetic/Surgical procedures to be performed:

PRE-ANESTHETIC BLOOD TESTING

It is important to understand that a pre-anesthetic profile does not guarantee the absence of anesthetic complications. It may, however, greatly reduce the risk of complications as well as identify medical conditions that could require medical treatment in the future.
Our greatest concern is the well-being of your pet. We will perform a physical examination before administering anesthesia. However, disorders of the liver, kidneys or blood, are not detected unless blood testing is done.
Abnormalities of any of these may increase anesthetic risk. For these reasons we highly recommend pre-anesthetic blood screens.
- Yes, I want the pre-anesthetic blood work.
- I decline the recommended pre-anesthetic blood work and understand the surgical risks.
MICROCHIP
MICROCHIP
- I authorize the doctor to microchip my pet while under anesthesia.
TATTOO
TATTOO
- I authorize for my pet to be tattooed to identify that it has been spayed or neutered.
INTRAVENOUS FLUIDS

Intravenous fluids given during surgery help maintain normal blood pressure and allow rapid administration of drugs should an emergency situation develop.
Authorization to Perform Surgical Procedure and/or Treatment
I, the undersigned owner or owner's agent, of the pet mentioned above the hereby authorize the doctors at Nash County Animal Hospital to perform the above anesthetic and surgical procedure(s) for my pet. I understand that some risk always exists with anesthesia and/or surgery, and that I am encouraged to discuss any concerns about those risks with the attending veterinarian before the procedure(s) is/are initiated.

I understand that Nash County Animal Hospital is not staffed overnight and I accept any risks incurred by leaving my animal overnight unattended. I understand that I have the option to transport my animal to an overnight/24 hour facility if I so desire.
Electronic Signature*
Best Contact Number For You Today*
Date*
MM slash DD slash YYYY

Nash County
Animal
Hospital

928 Eastern Ave
Nashville, NC, 27856
Phone: (252) 459-4001
Email: [email protected]

Hospital Hours
Mon - Fri: 7:30 AM – 5:30 PM
Saturday (1st & 3rd Of Each Month)
8:00 AM – 12:00 PM

Closed: Sundays

Cat wearing stethoscope

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