Dog Surgery Release in Black Creek, GA | Black Creek Animal Hospital

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Client Name:*

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Address:*

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Patient ID:*

Name:*

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Species:*

Breed:*

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Birth Date:*

Please answer the following questions regarding your pet's history:

Has your pet been vaccinated in the past year? If so, when? (Dhipp & Rabies)*

**if proof of current rabies vaccination status is not provided at the time of drop-off the vaccine will be administered.

Has your pet had a Heartworm test in the past year? If so, when?*

Is your dog on heartworm prevention? If so, what?*

Has your pet been checked for internal parasites in the last six months?*

Is your pet allergic to any medications? If so, what?*

A general pre-operative physical exam will be given to your animal before surgery to ensure their is no obvious problems that may affect anesthesia/surgery $20 A pain injection will be given at the time of surgery to keep your pet comfortable in the 24 hours following surgery $20

We highly recommend pre-surgical bloodwork to check for any underlying disease your animal may have that is not detectable on general physical exam. Such diseases include but not limited to blood disorders, kidney disease, liver disease, underlying infection, diabetes, etc. This may or may not affect surgical or anesthetic outcomes on your animal.

YES, I do want the Partial Junior Profile for my pet. $120.00 (6 months - 5 years)
YES, I do want the Partial Senior Profile for my pet, $150.00 (6 years - senior)
YES, I do want the Full Junior Profile for my pet. $208.00 (6 months - 5 years)
YES, I do want the Full Senior Profile for my pet. $238.00 (6 years - senior)
NO, I do not want any of the recommended blood panels for my pet.

We recommend post-operative pain medication to go home with your pet to ensure your pet does not experience pain while recovering from surgery.*

YES, I do want pain medication to go home for my pet.
NO, I do not want pain medication to go home.

A microchip can be implanted under your cat's skin at the time of surgery. If your pet ever gets lost and the pet is scanned your contact information is readily available so you can re-united. The cost is $55.95 and included lifetime registration.*

YES, please microchip my pet.
NO, please do not microchip my pet.

IF FLEAS ARE FOUND ON PET, A ONE-TIME PILL WILL BE ADMINISTERED TO TREAT THEM AT THE OWNER'S EXPENSE.

Phone number where owner can be reached:*

Surgery to be performed:*

Estimate*

I am the owner or agent for the above described animal and have the authority to execute this consent and authorization of the above named surgery(s). I understand that during the performance of the procedure(s), unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure(s), or even different procedure(s), that those set forth previously. I hereby consent and authorize the performance of such procedure(s) as necessary and desirable in the exercise of the veterinarian's professional judgement. I have been advised of the nature of the procedure(s), as well as the risks involved, and realize that results cannot be guaranteed. I additionally authorize the use of appropriate anesthesia, pathologist examination of excised tissue as deemed appropriate by the veterinarian, and the administration of other medications, and understand that hospital staff will be utilized as deemed necessary by the veterinarian. I have read understand this authorization and consent.

Date*

Signature of Owner or Agent (type full name)*

Dog Surgery Release

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