Pre-Operative Consent Form Pet's Name(Required) First Last Species(Required) Canine Feline Other Date(Required) MM slash DD slash YYYY Does your pet have any allergies to medications? If so, please list all medications.(Required) Yes No Specify:Does your pet have any food allergies? If so, please describe.(Required) Yes No Specify:Does your pet have any known medical conditions such as kidney disease, liver disease, heart disease, ect.?(Required) Yes No Specify:Please list any medications your pet is currently taking or has taken in the last two weeks, including over-the-counter products such as Benadryl.(Required) No Medications Specify:I would like a microchip placed in my pet while sedated at an additional cost that is not included in surgery fee.(Required) Yes No *A complimentary nail trim will be provided with any surgery.*Is your cat an indoor cat? (Only answer if applicable to your pet.)(Required) Yes No **Type of pre-anesthetic used for surgery will be done at the doctors’ discretion based on the needs of each individual pet.** **Pre-anesthetic bloodwork will be done to evaluate the health of all small animals prior to surgery at an ADDITIONAL COST. As the owner/agent, I authorize to execute this consent. I understand the risk of both surgery and anesthesia, and authorize consent to perform the following procedure(s):Good contact number(Required)Procedure(Required) Spay Neuter Dental Cleaning Growth Removal Other Specify:Signature(Required)Date(Required) MM slash DD slash YYYY CAPTCHA Δ
