Important Information for You:

Your pet can not eat after MIDNIGHT the night before the procedure.

Your pet can have access to water before the procedure.

Drop off time is between 7:45 AM – 8:10AM. Your exact Dropoff time will be emailed to you the night before your procedure.

Important Information from You:

What medications is your pet currently on, when was the last dose given? *

Does your pet normally get pre-visit (anti-anxiety) medications? *

What is the best number to contact you during the procedure? *

Please Note: We MUST be able to contact you during your pet’s procedure.

I authorize the staff of Austin Village Pet Hospital to perform the following procedure(s) on my pet:

Patient’s Name *

Procedure(s) *

Owner/ Responsible Party *

First

Last

Date of Procedure *

Email *

I understand all surgical, anesthetic and medical procedures contain inherent risk. I understand the success of any surgical, anesthetic or medical procedure involves a multitude of factors, many of which are beyond the control of the veterinarian and staff.

I understand that homecare administered by myself or a designated caretaker is recommended to achieve best overall success. It is my responsibility to notify Austin Village Pet Hospital before altering the doctor’s recommendations. I understand that changes, supplementation, or alteration of any prescriptions may possibly result in an unfavorable or detrimental side effect with medical complications.

I have discussed the risk and possible complications related to the above procedure to my satisfaction.

I understand that during the performance of medical, surgical, dental, or anesthetic procedures, unforeseen conditions or complications may be revealed that necessitate more extensive, costly, or different diagnostics or treatments than originally planned. If the staff at Austin Village Pet Hospital is unable to reach me, I hereby consent to and authorize the performance of such procedures and extractions as are marked and consented to below. I understand that the cost of such procedures may increase the final bill.

In addition, if I have an estimate more than 30 days old, I understand that it is my responsibility to request an updated version.

We MUST be able to reach you at ALL TIMES during your pet’s procedure and recovery.

Preference in event of unforeseen conditions/ complications or needed extractions

Call first with estimate, DO NOT proceed if unable to reach within 10 minutes. I understand that my pet will be woken up and recovered from anesthesia. This may result in a second anesthetic event at my cost for additional treatment.
Call first with estimate, proceed with recommended treatments that will increase the cost of the final bill if unable to reach within 10 minutes

Owner/ Responsible (eSignature) *

Date *

INCLUDED PROCEDURES:

PRE-SURGICAL VITAL SIGNS CHECK: Prior to beginning your pet’s procedure, we check their vitals to screen for any recent developments that would change our medical plans. INTRAVENOUS

CATHETER AND FLUIDS: For increased anesthetic safety, placed before surgery for delivery of fluids and/or medication to maintain blood pressure throughout the procedure.

SEDATED NAIL TRIM: We can perform our most accurate nail trim while your pet is sedated. This service is complimentary when you bring your pet in for surgery. *

Yes, trim nails
No, decline

OPTIONAL, BUT RECOMMENDED PROCEDURES:

(Please read carefully and check one choice for each item. These may not have been included in your estimate.)

If you have any questions about your options or why a procedure is recommended, please ask an AVPH staff member.

PRE-ANESTHETIC TESTING: Since anesthetics are removed from the body through the kidneys and/or liver, it is important to know that internal organ function and blood values are within normal limits. This is usually done before the day of the procedure for the most information at the best value. (Pre-anesthetic testing is required for all pets over 7yrs of age)

Do you authorize a pre-anesthetic blood screen ($200 same day charge)? *

Yes
No
Already Done

ANTI-NAUSEA TREATMENT: Nausea can be one of the most unpleasant parts of anesthetic recovery. This 24-hour injection of Cerenia® will help your pet feel better, guard against vomiting while your pet is under anesthesia, and get them back to eating and acting normally as quickly as possible. We feel strongly that this drug is a great benefit to many patients, and the cost of the injection is the only reason it is not automatically included with our sedated procedures.

Would you like your pet to be protected with Cerenia® for 24 hours? (0- 25lbs $45.00, 26-50lbs $60.00, 51-100 lbs $75.00, 100+lbs $90.00) *

Datamars® MICROCHIP IDENTIFICATION: Pet Link companion animal retrieval system permanently identifies your pet. The applied microchip and unique identification number used by Animal control and shelters can be used to reunite you and your pet through a national registry. This price includes lifetime registration in the Petlink database- we pay the registration fee for you. You may change your contact information at any time at www.petlink.net

Do you want your pet to be permanently identified with a microchip? ($ 65.00) *

Yes
No
Already Done

OPTIONAL, ADDITIONAL PROCEDURES:

EAR CLEANING: Some pets may have excessive debris in their ear canals that can cause redness, odor, and infection. Debris and inflammation cause the ears to be more sensitive and make the cleaning process uncomfortable or painful for your pet. If your pet needs its ears cleaned, pain and stress can be minimized by doing this while they are already anesthetized

Do you want your pet’s ears cleaned? ($15.00) *

EAR HAIR PLUCKING: Some dogs have excessive hair growth in their ear canals. In some cases, this hair can trap debris and infection. Plucking of the ear hair can cause some discomfort and stress on your pet can be minimized by removing the hair while the patient is already anesthetized.

Would you like to have your pet’s ear hair removed? ($15.00) *

SIGNATURE REQUIRED

This section applies to the entire page: I have read the preceding page and selected the options I am most comfortable with. Where noted, I understand that AVPH doctors may require services that I have not requested for the safety of my pet. I agree to pay for services rendered at the time they are completed. I have read the above, understand what it says and agree.

Owner/ Responsible Party (eSignature) *

Date *

Online Form

Surgical Consent Form