Surgery
Consent Form

Save time during your appointment. Complete your surgery consent form online from any device at any time before your visit.

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Surgery Consent Form

Please fill out this form as completely and accurately as possible so we can
get to know you and your pets before your visit.

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Owner’s Name *

First

Last

Pet(s) Name *

Email *

Phone where you can be reached (in case of emergency):

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Alternate Contact *

Alternate Contact Phone *

Please read the following carefully

Cole Veterinary Clinic’s mission is to provide quality, personalized care for your pet. With regards to anesthetic and surgical procedures, this means we treat every patient individually, and will make every possible effort to minimize risk during any anesthetic procedure. However, risk is still inherent with anesthesia, even in young, healthy patients; although rare, complications and death can sometime occur.

One way to minimize anesthetic risk is by doing a blood panel to assess proper internal organ function (effectively process and eliminate anesthesia from the body), and blood cell counts (anemia, infection, clotting assessment). Having this information can help the Vet make the most informed decision regarding anesthetic options and timing of anesthesia. In the event there is a severe abnormality, we will call you prior to proceeding with anesthesia. By INTIALING one of the following options I am providing informed consent for my pet’s anesthetic procedure today: *

Pre-Op Panel 1: A basic blood screen for healthy patients under 7 years of age
Pre-Op Panel 2: A more comprehensive panel for older pets or with a known medical problem
DECLINE pre-anesthetic testing

When was the last time your pet ate (including any treats)? *

Please list any medications or supplements your pet is taking, or has taken in the past two weeks and the last time they received the medication:

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Medication, Dosage, and Frequency

Medication, Dosage, and Frequency *

Medication, Dosage, and Frequency

Time Last Dose was Given

Time Last Dose was Given *

Time Last Dose was Given

Would you like your pet to have a Home Again Microchip ($54.49, including Registration) implanted while they are under anesthesia? *

I am the owner or authorized agent of the patient being admitted for surgery and understand that full payment is due at the time of discharge. I acknowledge that I have received an estimate for today’s procedure. *

In the rare event of an emergency complication in which phone authorization cannot be obtained, either through non- answer or immediate time constraints, I authorize the Doctors and their staff to provide the necessary critical care and resuscitation efforts. I understand that this may incur additional expenses. *

I authorize

Owner/Authorized Representative *

Date *

Surgery
Consent Form

Surgery Consent Form

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