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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
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Last
Email
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Primary Phone Number
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Can we text this number?
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Secondary Phone Number
Can we text this number?
Yes
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Pet's Name
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Procedure
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Additional services request - I would like NSVC to perform these additional treatments while my pet is in the facility:
Nail trim with anesthesia ($7)
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.
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I have read and understand
Patient Medical History
Current diet
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Is your pet taking any medications?
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No
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Medication #1
Medication/Supplement Name
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Dosage
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Time last dose was given
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Add a second medication?
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Yes
No
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Medication #2
Medication/Supplement Name
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Dosage
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Time last dose was given
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Add a third medication?
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Medication #3
Medication/Supplement Name
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Dosage
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Time last dose was given
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Add a fourth medication?
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Medication #4
Medication/Supplement Name
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Dosage
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Time last dose was given
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Any prior reactions/allergies to medications?
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Yes
No
If yes, please describe
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Has your pet shown recent signs of illness such as loose or decreased bowel movements, lethargy or sneezing?
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Yes
No
If yes, please describe
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Has your pet shown changes in appetite, drinking or activity level?
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Yes
No
If yes, please describe
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Please list any other concerns about your pet
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Please list any belongings to be left with your pet
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(The clinic will not be responsible for lost items.)
Are you bringing food for your pet?
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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.)
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I have read and understand
Signature
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Today's Date
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