Date *

Pets Name *

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

I agree

I understand that there is always a risk of contracting infectious diseases/viruses at an animal hospital, and I do not hold Good Shepherd Pet Hospital liable or financially responsible in any way if your pet contracts anything while in our 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. *

Yes

I consent to emergency treatment without my approval. The doctors and staff at Good Shepherd Pet Hospital will do our best to try and contact you for any additional treatment or emergencies. Please leave all available numbers to reach you at. If emergency treatment is required there will be additional fees incurred. *

I agree
I do not agree

I DO understand that there is no treatment staff on the premises after closing hours. Any pet not picked up by 6:00 pm (Tues-Fri) OR 5pm (Sat/Sun) will be kept overnight and charged a boarding fee. Please call ahead if you are not able to make it *

I understand

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 termination of pregnancy at the time of spaying my pet. I understand that there is an additional fee for this and take full responsibility for this procedure. I also understand that there will be an additional fee if my pet is lactating, in heat, or obese. Prices range from $175-$250. (Like you, our greatest concern is the well-being of your pet, the following procedures are recommended to ALL patients being put under anesthesia. These procedures are recommended by our doctors but are optional and additional in cost.)

I understand

Bloodwork

Before putting your pet under anesthesia a blood analysis will be performed to ensure that your pets’ vital organs are functioning in a normal and healthy manner or that they do not have an infection. These simple blood tests will allow us to make sure that your pet is in the physical health required for us to administer anesthesia.

I understand bloodwork will be performed prior to procedure.

I understand

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

Yes
No

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.

I understand

Pain Medication

This procedure provides after surgery pain relief to your pet. It includes an injection for pain after the procedure as well as pain medication to go home with them.

I understand pain medication will be administered during procedure.

I understand

Laser Therapy

We offer laser therapy which accelerates healing, reduces pain, and reduces inflammation.$29.75 *

Yes, I would like laser therapy on my pet today.
No, I would not like to use laser therapy today.

Microchip

This can be installed at any time; however, the needle is fairly large and is recommended to have it done when your pet is already under anesthesia. There is a onetime fee of $49.00. *

Yes, I would like a microchip for my pet.
No, I would not like a microchip for my pet.

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 described above. I certify that I am eighteen (18) years of age or older. I understand that if I am not the owner, or the owners’ authorized agent, or if I am not over 18, I must NOT sign this form and must bring this information to the staff. I, the undersigned owner or authorized agent of the admitted patient, authorize Good Shepherd Pet Hospital (Its doctors and staff) to administer such treatments and anesthetics, both standing and emerging are necessary to perform the above-mentioned procedure(s). Further, I understand why such diagnostics, medical and/or surgical procedures are recommended. Their advantages and possible complications, as well as possible alternative modes of treatment due to unforeseen conditions or otherwise, have been explained to me. I understand that no guarantee of successful treatment is either made or implied. I understand that there are many risks with putting my pet under anesthesia. I understand that it is hospital policy that all charges are due and payable upon my pets’ release unless other arrangements have already 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 Call
Text

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

Yes
No

Client Signature *

Clear Signature

Date of Signature

Anesthesia Release and Surgery Consent Form

For Dentals Only

For Female Spays Only

Bloodwork

Fluid Therapy

Pain Medication

Laser Therapy

Microchip

E-Collar

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