Surgical Consent Form

Complete the form below or download the form to complete it at your convenience.

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Name *

First

Last

Email *

Pet's Name *

Scheduled Procedure *

Date *

These procedures, the medical necessity and costs have been explained to me to my satisfaction. I understand that I may call for updates on my pet as I deem appropriate. I understand that no guarantee has been made to me regarding the outcome of my pet’s treatment or procedure. *

I have read and agree.

I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns with the attending veterinarian before the procedure is initiated. Should some unexpected life- saving emergency care be required, and the attending veterinarian be unable to reach me, I consent to additional treatment at the discretion of the attending doctor and agree to pay for all related fees. I accept that veterinary medicine is an inexact science and that no guarantee of successful treatment has been made. *

I do consent to additional treatment at the discretion of the attending doctor and agree to pay for all related fees.
I do NOT consent to additional treatment at the discretion of the attending doctor and agree to pay for all related fees.

Our greatest concern is the well being of your pet. We will monitor your pet’s heart rate, respiratory rate, blood oxygen, blood pressure and EKG during surgery. This technology along with pre-anesthetic blood screening reduces many of the risks of surgery. We strongly recommend pre-anesthesia blood work prior to anesthetizing your pet. Many conditions including disorders of the liver, kidneys and blood may not be detected unless blood testing is performed. *

YES, I want my pet to have CBC & Chemistry blood work completed prior to Anesthesia
NO, I do not want my pet to have CBC & Chemistry blood work completed prior to anesthesia. I have been informed of the risks associated with declining this bloodwork.

(***Mandatory blood work is required for all animals over 6 years of age***)

Please select the vaccines for which your pet is currently due, if any:

*Animals are REQUIRED to be up to date on vaccines in order to have surgery

Is your pet currently receiving any medications? If yes, Please list medications and dose below.

I understand that an estimate of the costs for veterinary services will be provided to me and that I am encouraged to discuss all fees related to such care before services are rendered and during this pet’s ongoing medical treatment. If your pet is hospitalized, I agree to pay a deposit of 50% of the estimated fees at the time of hospitalization and assume financial responsibility for the balance of all services rendered, due in full on a cash, credit card, CareCredit, or check basis at the time your pet is discharged. If <animal> is hospitalized beyond the first day at this facility, I understand that veterinary care during nighttime hours and/or weekends is provided at the discretion of the attending veterinarian. Continuous presence of personnel is not provided during these hours. ***PLEASE NOTE: Our hospital policy is to keep all surgery patients overnight unless you are informed otherwise by a Technician or Doctor*** *

I have read and agree.

I, being responsible for my pet, having the authority to do so, grant you my consent to receive treatment, prescribe for and/or operate upon my pet as noted above. I also agree that after consultation with me, the hospital’s doctors may prescribe medication for, treat, hospitalize, sedate, anesthetize and/or perform surgery on the animal. GPVH is to use all reasonable precautions against injury, escape or death of my pet, but is not held liable or responsible in any matter, as I thoroughly understand I assume all risks. I, the undersigned owner, authorized agent of the owner, or Good Samaritan responsible for seeking veterinary care am over eighteen years of age. *

I have read and agree.

Signature *

Please type your name.

Date *

Phone number where I can be reached: *

Phone

Proudly caring for the pets of the Laurel Highlands and beyond.

It is our mission to partner with our clients to nurture and preserve the human-animal bond by providing compassionate, expert, and affordable veterinary care from your pet's first adventure throughout a long and healthy life.

Contact

Phone: 814-444-6809
Fax: 814-444-6843
Email: info@gladespikevet.com

Location

917 W. Main St.
Somerset, PA 15501

Hours

Mon - Tue: 8 AM - 6 PM
Wed: 8 AM - 8 PM
Thu - Fri: 8 AM - 6 PM
Sat - Sun: Closed

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