Surgery Consent Form

Centennial Animal Hospital Surgery Consent Form

Thank you for giving Centennial Animal Hospital the opportunity to care for your
pet(s). During this time, we are asking all clients to fill this out prior to their pet’s scheduled surgery.

Name(Required)

First Last

Email(Required)

Phone(Required)

Pet's Name(Required)

Date of Surgery(Required)

MM slash DD slash YYYY

Surgical Procedure(Required)

If 'Other', please explain what kind of surgery:(Required)

Would you like to be contacted by text before your pet goes in for the procedure?(Required)

Yes

What is the best phone number to text you?(Required)

After the procedure, would you prefer a text or a call?(Required)

Text

Call

Does your pet take daily medications (prescription or over the counter)?(Required)

Yes

If yes, please list name, dosage, and frequency for each medication(Required)

As the owner/agent; I hereby consent and authorize the performance of the following procedures/treatments.

Surgical procedure includes: Pre-surgical exam, pre, and postoperative medications, and an IV catheter with fluids. Possible dental X-ray(s) and extraction(s) when applicable.

Pre-Surgical Blood Work: This is required for all surgical patients regardless of age.

Microchip: We offer Microfindr to all our clients, and the cost is $55.00. Microchips are designed to help identify lost pets and reunite them with their owners. One in three pets are lost during their lifetime, and only one in ten lost pets is found.

I have been advised as to the nature of the procedure(s) and the risks involved. I realize that the results cannot be guaranteed. I am aware that THERE ARE RISKS WITH ANY ANIMAL GOING UNDER ANESTHESIA and know that the veterinarian will take all necessary precautions.(Required)

I have read and understand.

I understand that during the performance of the procedures/treatments, unforeseen conditions or problems may be revealed that necessitates an extension of the procedure(s) or that different procedures than those set forth above may become necessary. Therefore, I consent to and authorize the performance of any such procedure(s) the veterinarian deems necessary. The staff of Centennial Animal Hospital will contact me as soon as medically able to inform me of any changes in my pet's condition.(Required)

I have read and understand.

I also authorize the use of appropriate anesthetics and other medications, and I understand the hospital support personnel will be employed as deemed necessary by the veterinarian.(Required)

I have read and understand.

I agree to pay today in full for services rendered, including those deemed necessary for medical or surgical complications or unforeseen circumstances. Furthermore, I understand that regardless of the outcome of the procedures, I am responsible for payment of the procedures immediately.(Required)

I have read and understand.

It can be difficult to predict if teeth need extraction when an animal is awake because tartar and movement interfere with the assessment. Severely diseased teeth can cause considerable pain/discomfort and are a source of infections for other organ systems (liver, kidney, lungs, & heart). During the dental cleaning, the teeth are evaluated, and if found to be diseased, they may require an extraction or referral to a dental specialist for repair. The cost of extractions varies depending on the difficulty and can range from $40.00 - $85.00 per tooth. We will always call if we note an area of concern, but if we cannot reach you for some reason, please indicate (initial) below how you would like us to proceed.(Required)

I authorize all medically necessary extractions to be performed and understand that I will be responsible for paying all charges today.

I authorize all medically necessary extractions up to $______ (extraction cost only) to be performed and that I will be responsible and pay all charges today.

If I cannot be contacted by phone, I do not authorize any extractions to be performed. *Please be aware that if you decline any needed procedures at this time, your pet will need a second anesthesia at another time for those procedures to be performed at additional cost.

I would prefer to seek out a dental specialist for further treatments such as root canals, fillings, and orthodontics.

Does not apply.

Please list the dollar ($) amount you authorize below. If not applicable, please write 'N/A':(Required)

I AM AT LEAST 18 YEARS OF AGE. I have read and understood this authorization and have the authority to execute this consent.

I have read and understand.

Owner's Signature(Required)

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Date(Required)

MM slash DD slash YYYY

We treat your pets like the valued family members they are.

Address

6870 Centennial Blvd.
Colorado Springs, CO 80919
Click here for directions.

Hours

Mon – Fri: 8:00 am – 6:00 pm
Sat: 8:00 am – 12:00 pm
Sun: Closed

Contact

Phone: 719-528-1693
Fax: 719-528-1694
Email: centennialpets@gmail.com

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