SURGERY AUTHORIZATION | My Site 1

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First name*

Last name*

Best Contact Number for Today*

Pet's Name*

What procedure is your pet getting done today? *

Is there anything else you would like Dr Chavis to address today?

Pre-operative blood work within past 30 days?*

Yes

No

I elect to have blood work performed in the clinic today. In house blood work is $175*

Yes

No

An e-collar is recommended for all surgeries. Do you want one today? The e-collar is an additional $28*

Yes

No

Would you like your pet microchipped? The microchip is an additional $60*

Yes

No

Would you like at home oral sedation? The cost of at home sedation is an additional $30. (We strongly recommend this to prevent post op swelling and other potential complications that can be caused from too much activity.) *

Yes

No

I understand that unforeseen conditions may be revealed during the procedures that may require more extensive or different treatments. I have chosen which diagnostics and procedures to be performed for my pet in relation to my pet's risk associated with *

I understand

I do not understand and need more clarification

I understand that I assume financial responsibility for all services rendered. I also understand that full payment is due when services are rendered.*

I understand

I do not understand and need more clarification

I understand that if my pet is being spayed and she is pregnant we MUST proceed with the procedure, the anesthesia is detrimental to the development of the fetus. There is an additional charge of $70, this covers additional surgery time. *

I understand

I do not understand and need more clarification

I understand the procedure(s) identified in this consent form and they have been explained to my satisfaction. I understand the reason for the procedure and the risks involved. I realize that there can be no guarantee as to the outcome of any procedures.*

I understand

I do not understand and need more clarification

I hereby authorize surgery/anesthesia for my pet. I understand that some risks always exist with anesthesia or surgery and include but are not limited to infection, cardiovascular disease, neurologic disease, disfigurement and rarely, death. *

I authorize

I do not authorize

I acknowledge these risks and understand that the veterinarians and hospital staff will try to minimize such risks. I also understand that I have elected certain tests or procedures that will affect the risk associated with anesthesia for my pet.*

I acknowledge

I do acknowledge and need more clarification

I will not hold Countryside Companion Veterinary Services, the attending veterinarian, or any staff member liable for any complications that may arise.*

I will not hold CCVS liable for complications.

If my pet is overweight or obese, the risk of anesthesia is higher and may results in adverse effects such as taking longer to go under anesthesia, having a prolonged recovery or possibly death. *

I understand

I do not understand and need clarification

My pet is not considered overweight/obese

If life-threatening complications do occur, I do/ do not authorize the attending veterinarian/staff to do everything possible to maintain the health/life of my pet (perform CPR).*

I do elect CPR

I do not elect CPR

When was your pet's last meal*

Is your pet on any medications/supplements? List names and times given of medications*

I have read and understood all of the information in this form. *

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Surgery Authorization Form

Our hours of operation are from 8AM – 3PM. If you or another designated person cannot pick up your pet before 3PM, an additional fee will be added to your final invoice.
Pickups between 3PM and 3:15 PM will result in a $25 charge.
Pickups after 3:15PM will result in overnight boarding for your pet at the cost of $35 per night.

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