Surgical & Medical Consent Form

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

Pet’s Name(Required)

Species:(Required)

Sex:(Required)

Color:(Required)

Markings:(Required)

Age:(Required)

Anesthetic /Surgical Procedures to be performed(Required)

When will be the last time your pet will eat prior to surgery? (Please pick up food after midnight the night before; water is okay to have up until surgery to prevent dehydration.)

Is your pet taking any medications?(Required)

Yes

If so what and when?(Required)

Last dose of heartworm prevention(Required)

DIAGNOSTIC BLOOD TESTING (required for pets 7 years and older) $133.89(Required)

Please perform this testing on my pet

I decline to have this testing performed on my pet

We recommend a blood panel be run prior to surgery to help detect any internal problems that may post a potential risk while your pet is under anesthesia.

POST SURGICAL LASER $15.38(Required)

Please perform this procedure on my pet

I decline the procedure at this time

We recommend a laser treatment following surgery in order to expedite the healing process, help decrease pain, and shorten down time.

MICROCHIPPING protects your pet if lost and taken to a shelter or vet office. $42.66(Required)

Please perform this procedure on my pet

I decline the procedure at this time

E-COLLAR (if applicable)(Required)

Yes, I DO want an e-collar.

No, I DO NOT want an e-collar.

We recommend an e-collar be worn for up to 2 weeks post-surgery to prevent licking at the incision, which can cause it to open or become infected. Would you like an e-collar sent home today? If you select NO, you accept full responsibility for any self-trauma.

Consent to perform extractions and necessary procedures of dental cleaning (prophylaxis)(Required)

Please perform any necessary procedures and extractions at this time.

Please call me after the dental exam and advise me of anticipated additional procedures/extractions

Many pets require sedation before a doctor can complete a thorough dental exam. Each tooth must be carefully evaluated so the veterinarian can choose the best treatment. We recommend completing all needed dental procedures during this visit so you can avoid scheduling another appointment with additional sedation costs.

Additional charges will be incurred if your pet is in heat, pregnant or cryptorchid (retained testicles). Growth removal procedures do not include histopathology; please advise us if this is requested. Pets that are overdue for vaccines are required to be made current during time of hospitalization. To lesson the risk of anesthesia/surgical procedures all dogs over the age of 6 months must be current on heartworm testing/and or preventative medication. To maintain a flea free environment, an appropriate product will be used if fleas are present (at the expense of owner)

I, being the owner or responsible party for the above name animal, grant permission to the agents of York Veterinary Services to administer anesthetics or other drugs as deemed advisable for, and/or perform surgical, and/or medical procedures upon my pet. I understand the nature of the procedures and I am aware of the risks involved and release York Veterinary Services from any legal and financial responsibilities arising from complications.

We will gladly provide an estimate for estimate for services. Estimate given?(Required)

Yes

I understand that my pet has to be fully vaccinated or receive all vaccines while here in order to be kept in the hospital. If applicable, I also understand that deposits are required for certain hospital procedures. I give York Veterinary Services permission to do what is necessary for my pet unless above noted. ** I, being the owner or responsible party for the above name animal, grant permission to the agents of York Veterinary Services to administer anesthetics or other drugs as deemed advisable for, and/or perform surgical, and/or medical procedures upon my pet. I understand the nature of the procedures and I am aware of the risks involved and release York Veterinary Services from any legal and financial responsibilities arising from complications.(Required)

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