Anesthesia & Surgical Consent Form

Name: McFarland Animal Hospital
Address: 5620 HWY 51, McFarland, WI, 53558, United States
Telephone: 608-838-3400
Price range: $

APPOINTMENT

Thank you for giving us the opportunity to care for your pet. Please fill out this form as completely and accurately as possible!

Name(Required)

First Last

Email(Required)

Pet's Name(Required)

Surgery(Required)

Date(Required)

MM slash DD slash YYYY

Pre-Surgical Bloodwork: Fees quoted below include pre-surgical bloodwork and exam to screen for potential problems that may arise during anesthesia and recovery. Many conditions including disorders of the liver, kidney, and blood are often undetected without bloodwork screening. Occasionally, a surgical procedure might need to be postponed in order to treat an underlying condition. For pets over the age of seven, comprehensive bloodwork is highly recommended. Please select the bloodwork option you prefer today:(Required)

I decline bloodwork for my pet today.

Comprehensive (Chem17 (organ function panel), Glucose, Electrolytes, Complete Blood count) ($145)

Basic (Chem10 (organ function panel), Red Blood Count, Hydration Status) ($90)

Mass Removal: If your pet is here for a mass removal today, please indicate if you wish to have the mass sent to the laboratory for diagnosis. The results will be available 7-14 days after it is received.(Required)

Yes, please perform a histopathology. ($158.77)

No, I do not want histopathology.

Additional Services Requested:

Check all that apply.

Fluoride Treatment ($9.35)

Nail Trim ($0)

Canine Rabies ($35)

Canine Distemper ($46.15)

Canine Lyme ($39.75)

Canine Bordetella ($25.95)

Canine Influenza ($37.35)

Heartworm Test ($45.75)

Heartworm & Tick Panel ($67.75)

Feline Rabies ($44.75)

Feline Distemper ($46.15)

Feline Leukemia ($39.65)

FIV/FeLV Snap ($57.00)

Fecal Exam ($26)

Ear Cleaning ($19.75)

Ear Exam ($20.75)

Anal Glands($23.75)

Sanitary Clip ($18.75)

Microchipping ($57.75)

Current Medical History

Has your pet ever had complications with anesthesia?(Required)

Yes

Not applicable

Does your pet have known food or drug allergies?

Yes

If yes, describe:(Required)

Does your pet have any history of seizure activity?(Required)

Yes

Does your pet have a heart condition or murmur?(Required)

Yes

Is your pet currently taking medications?(Required)

Yes

List all medications your pet is currently taking:

Did your pet take their medication this morning?(Required)

Yes

Patients must be fasted prior to anesthesia. When did your pet eat or drink last?(Required)

I, the undersigned owner of the pet identified above, certify that I am 18 years of age or over and am able to authorize the veterinarian(s) and support staff at McFarland Animal Hospital to perform the above elected procedures.(Required)

I have read and understand.

I understand that some risk exists with anesthesia and/or surgery and the recovery from these events. I am encouraged to ask questions and discuss any concerns that I have about those risks with the attending doctor prior to the initiation of the procedure(s). My signature below indicates that my questions regarding the following issues have been answered to my satisfaction: [1] The reasonable medical and/or surgical treatment options for my pet. [2] Sufficient details of the procedure(s) to understand what will be performed. [3] How fully my pet will recover and how long it will take. [4] The most common and serious complications and risks. [5] The length and type of follow-up care and home restraint required. [6] The estimated fees are associated with all procedures to which I have consented. [7] I have reviewed a copy of the Surgical Information Form from McFarland Animal Hospital(Required)

I have read and understand.

While I accept that all procedures will be performed to the best abilities of the staff at McFarland Animal Hospital, I understand that medical outcomes cannot be guaranteed and that no warranty has been made regarding the results that may be achieved. I understand that estimated fees do not include the cost of potential complications. I understand that rabies and distemper are required to be up to date for all surgical patients and consent to their administration if necessary. I understand that payment is due in full before my animal is released.(Required)

I have read and understand.

On the day of your pet's surgery, it is important that we are able to call you if anything occurs that is not planned or estimated in advance, if such a situation arises, please select the option best suitable for you and your pet so that the anesthetic procedure can continue uninterrupted. If we cannot reach you and additional procedures are necessary your pet will need to return at a later date and the full cost of the procedure will be charged. We cannot keep a pet under anesthesia longer than necessary. Please be aware that during a life or deather event, we will attempt to stabilize your pet before calling for authorization. Select one option in case of an unexpected event:(Required)

Please perform whatever surgical or diagnostic procedures the Doctor deems necessary for my pet.

I authorize up to a specific amount (specify below) in additional procedures, including extraction costs.

Do not perform any additional procedures until authorization is given.

Specific amount:(Required)

Primary phone number:(Required)

Secondary phone number:(Required)

Signature(Required)

Date(Required)

MM slash DD slash YYYY

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Phone

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