Consent for Surgery

Client Name*

Date*

Patient Name*

D.O.B.*

Surgical Procedure*

I hereby authorize that I am the owner of the above mentioned patient and have the authority to give Mile Creek Animal Hospital and Dr. Winner permission to perform the above mentioned surgical procedure(s).

Does your pet need any other treatments today?

Other - please list

Histopath

Yes
No

Microchip Identification

Very few lost pets find their way home without permanent identification. We can implant a MICROCHIP while your pet is sedated for $56.00 (REDUCED COST if done at surgery time is $40.00)

Yes
No

In a continuing effort to provide quality healthcare to our patients and reduce anesthetic risk, we recommenda pre-surgical blood panel. This blood work will check liver and kidney function, blood proteins, and blood glucose levels before your pet is administered any anesthesia. The liver and kidneys are the prime organs that metabolize the anesthetic drugs weuse and it is possible to have elevations, indicating improper function, with no physical symptoms. Blood proteins give a complete pictureof liver function and hydration status. Blood glucose levels ensure your pet’s sugar is at an appropriate level. This blood work gives us a more complete picture of howyour pet’s body is functioning.

I give consent to perform pre-surgical blood panel
I decline the pre-surgical blood panel

Does your pet have any of the following symptoms?

Other - please list

Your pet will be examined prior to any procedure, to ensure they are in good health and able to undergo the mentioned procedure(s). If any abnormalities are found, it will be up to Dr. Winner’s medical opinion if she thinks it is safe to proceed. You will be notified of any problems found on physical exam or pre-surgical blood panel.

I understand that the bill must be paid in full at the time of discharge, including any charges accrued in the event of unforeseen medical or surgical complications*

Yes
No

I give Mile Creek Animal Hospital permission to perform any necessary procedures should an anesthetic emergency arise, and do what Dr. Winner feels is necessary to preserve the life of my pet in the event that I am unable to be reached.*

Yes
No

In the event of an anesthetic emergency, I do not wish for my pet to be resuscitated*

Yes
No

Signature of Owner / Agent*

I have read the above information, have had the procedure explained to me, and understand the risks of surgery

Emergency Contact Number(s)*

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Our Address

Hours

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