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Small Mammal Surgical Consent Form

Please fill out this form as completely and accurately as possible.

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Owner's Name(Required)

First Last

Email(Required)

Primary Phone Number(Required)

Can we text this number?(Required)

Yes

No

Secondary Phone Number

Can we text this number?

Yes

No

Pet's Name(Required)

Procedure(Required)

Additional services request - I would like NSVC to perform these additional treatments while my pet is in the facility:

Field

Nail trim with anesthesia ($7)

Field

Endoscopic oral exam (cost $99, already included with teeth trim procedures) - Rabbits and Guinea pigs have teeth that continue to grow throughout their lifetimes. These pets may develop a malalignment of their teeth that may cause difficulty chewing, weight loss, pain and infection. Due to the anatomy of their mouths, anesthesia and endoscopic equipment are required to assess their teeth.

I understand that no guarantee or warranty for success or outcome can be given and that some risks are involved in all anesthetic procedures. The risks have been explained to my satisfaction and North Seattle Veterinary Clinic has my permission to perform the procedures as listed above. I understand North Seattle Veterinary Clinic is not open for overnight care and is not staffed by a medical team after hours. I understand that I assume financial responsibility for all services rendered, and that payment is due at the time I pick up my pet.(Required)

I have read and understand

Patient Medical History

Current diet(Required)

Is your pet taking any medications?(Required)

Yes

No

Hidden

Medication #1

Medication/Supplement Name(Required)

Dosage(Required)

Time last dose was given(Required)

Add a second medication?(Required)

Yes

No

Hidden

Medication #2

Medication/Supplement Name(Required)

Dosage(Required)

Time last dose was given(Required)

Add a third medication?(Required)

Yes

No

Hidden

Medication #3

Medication/Supplement Name(Required)

Dosage(Required)

Time last dose was given(Required)

Add a fourth medication?(Required)

Yes

No

Hidden

Medication #4

Medication/Supplement Name(Required)

Dosage(Required)

Time last dose was given(Required)

Hidden

Reset Conditional

Any prior reactions/allergies to medications?(Required)

Yes

No

If yes, please describe(Required)

Has your pet shown recent signs of illness such as loose or decreased bowel movements, lethargy or sneezing?(Required)

Yes

No

If yes, please describe(Required)

Has your pet shown changes in appetite, drinking or activity level?(Required)

Yes

No

If yes, please describe(Required)

Please list any other concerns about your pet(Required)

Please list any belongings to be left with your pet(Required)

(The clinic will not be responsible for lost items.)

Are you bringing food for your pet?(Required)

Yes

No

If applicable, please list the type and latest dose of flea medication provided to your pet.

Please list any behavioral or handling concerns (fearful, aggression, pain etc.)

The information provided on this form is true to the best of my knowledge. I also accept that if evidence of live fleas is found on my pet that a dose of flea medication will be given to my pet at a cost not to exceed $26. (This policy protects your pet as well as others in the clinic.)(Required)

I have read and understand

Signature(Required)

Today's Date(Required)

MM slash DD slash YYYY

Comments

This field is for validation purposes and should be left unchanged.

Why Choose Us

Our professional and courteous staff at North Seattle Veterinary Clinic seek to provide you with the best possible medical, surgical, and dental care for your beloved pets.

Request a Refill

For prescriptions filled directly by us, please allow 24 hours to complete your request. Requests made over a weekend will require extra time to fill.

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