Surgery Consent Form

Review and complete the surgery consent form online to ensure a smooth process for your pet’s upcoming procedure. Your details are vital for us.

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Surgery Consent Form

Please complete the surgery consent form online, ensuring all details are filled out correctly. This helps us prepare for your pet’s procedure efficiently.

Date *

Pet's Name *

I consent to the administration of anesthetics and to all procedures as described to me by the veterinarians and staff. *

I agree

I understand that there is an inherent risk of contracting infectious diseases or viruses at an animal hospital. I agree not to hold Little Road Veterinary Clinic liable or financially responsible should my pet contract any illness while in your care. *

I understand

To the best of my knowledge, my pet is healthy and had no signs of illness, such as vomiting, diarrhea, coughing or sneezing; and that my pet has had no food or water since 10 pm last night. *

I agree

Emergency Treatment Consent: *

I agree to emergency treatment being administered without my prior approval. I understand that the veterinarians and staff at Little Road Veterinary Clinic will make every effort to contact me regarding any additional treatment or emergencies. I acknowledge that immediate action may be taken if necessary, and additional fees may apply. I will provide all available contact numbers.
I do not agree to emergency treatment being administered without my prior approval. I understand that this may impact the availability of care for my pet in urgent situations.

I understand that if fleas are seen on my pet, flea product will be applied immediately. We cannot have fleas on the sterile surgical site, so this is NOT an option. The last time flea meds were applied was:

Every pet here today will receive a pre-surgical exam. Often, we find retained baby teeth, umbilical hernias, and restrained testicles. If we find any of these issues during the pre-surgical exam, we will call you and give you the option to have them repaired. There are additional costs for these services.

I agree

For Dentals Only

I consent to all extractions. I understand that extractions are at an additional cost, the price is depending on how complicated the extraction is. The minimum charge per tooth is $50.00 *

I agree
I do not agree

For Female Spays Only

I hereby authorize the termination of pregnancy during the spaying procedure for my pet. I understand that there is an additional fee for this procedure and accept full responsibility for it. Additionally, I am aware that there will be extra charges if my pet is lactating, in heat, or obese, with prices ranging from $175 to $250. At Little Road Veterinary Clinic, our primary concern is your pet’s well-being. While the following procedures are recommended for all patients undergoing anesthesia, they are optional and will incur additional costs. *

I understand

Bloodwork

Before administering anesthesia, a blood analysis will be conducted to ensure your pet’s vital organs are functioning properly and to check for any infections. These essential blood tests help us confirm that your pet is in the necessary physical health for anesthesia at Little Road Veterinary Clinic. *

I understand that bloodwork will be performed prior to procedure.

My pet has already had the necessary bloodwork performed one month prior to procedure. *

Fluid Therapy

An IV catheter is placed and LRS fluids are given through the IV before, during and after the procedure(s). This assists your pets’ kidney and live to flush the anesthesia through their system and keeps their blood pressure normal during the procedure(s). This also allows them to stay comfortable by keeping them hydrated during and after the procedure(s). *

I understand fluid therapy will be administered during procedure.

Pain Medication

This procedure ensures your pet receives pain relief after surgery. It includes an injection to manage pain immediately following the procedure, along with prescribed pain medication to take home. *

I understand pain medication will be administered during procedure.

E-Collar

We recommend all pets who have surgery to wear a cone. This helps prevent your pet from licking or chewing on the surgery site. *

Yes, I would like an e-collar for an additional cost of $27.
No, I do not want to purchase an e-collar.

I have read and fully understand the terms and conditions outlined above. I certify that I am eighteen (18) years of age or older. If I am not the owner, an authorized agent of the owner, or if I am under 18, I acknowledge that I should not sign this form and must present this information to the staff. As the undersigned owner or authorized agent of the admitted patient, I authorize the veterinarians and staff at Little Road Veterinary Clinic to administer any necessary treatments and anesthetics to perform the procedures described. I understand the reasons for the recommended diagnostics, medical, and/or surgical procedures, including their advantages, potential complications, and possible alternative treatments. I acknowledge that no guarantee of successful treatment is made or implied and recognize the inherent risks associated with anesthesia. I also understand that, as per hospital policy, all charges are due and payable upon my pet’s release unless other arrangements have been made. *

I have read and fully understand.

Owner/Agent Name *

First

Last

Email *

Phone Number *

Alternative Number

Emergency Contact Name

Emergency Phone

Preferred way to receive communication for updates and discharge: *

Phone
Text

I, the undersigned owner or agent of certify that I am 18 years or Older. *

Client Signature *

Clear Signature

Date of Signature *

Surgery Consent Form

Surgery Consent Form

For Dentals Only

For Female Spays Only

Bloodwork

Fluid Therapy

Pain Medication

E-Collar

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