Pet Details

Pet Name(Required)

Name

Breed(Required)

Species(Required)

Sex(Required)

Male

Female

Male Neutered

Female Spayed

Weight

Date of your pet's appointment(Required)

Owner Details

Name(Required)

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email(Required)

Phone number where you can be reached AT ALL TIMES the day of your pet's procedure *(Required)

Does this number accept text/SMS? *(Required)

Yes

Please do not text - phone calls only.

Secondary phone number (and name of contact if different than you)

Does this number accept text/SMS?

Yes

Please do not text - phone calls only.

PATIENT MEDICAL HISTORY

Please list all medications or supplements your pet is taking - include 1) Name of item 2) Dosage 3) Time last given(Required)

Any known reactions or allergies to medications or vaccinations?(Required)

Yes

If yes, Please describe:

Has your pet shown recent signs of illness such as vomiting, diarrhea, coughing or sneezing?(Required)

Yes

If yes, Please describe:

Has your pet shown changes in appetite, drinking or exercise habits?(Required)

Yes

If yes, please describe:

Please list any other concerns about your pet:(Required)

Please list any belongings left with your pet (The clinic will not be resoponsible for lost items.):(Required)

Please list any behavioral or handling concerns (fear biting, dog aggression, pain, etc.):(Required)

PRE-ANESTHETIC TESTING

A veterinarian will perform a physical exam to assess your pet's overall health prior to giving any anesthetic medications. To better assess internal organ health we offer a pre-anesthetic blood panel to be performed prior to the procedure. See the attached form on blood panels for details. For patients under 7 years of age, this is optional for clients. It is important to understand that pre-anesthetic profile does not guarantee the absence of complications. It may, however greatly reduce the risk of complications and identify medical conditions that could require medical treatment in the future.

For patients under 7 years old:(Required)

Please proceed with pre-anesthetic blood testing

I decline the recommended pre-anesthetic blood work and understand there may increased risks during anesthesia.

In patients 7 years and older NSVC requires Pre-anesthetic blood profile and measurement of blood pressure Within 3 months of the procedure.

ADDITlONAL SERVICES

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

Nail trim

Ear Cleaning/Flush

Anal gland draining/expression

Microchip Placement

Fluoride Treatment

Give Vaccinations Due

Deciduous Tooth Extraction - Removing any baby teeth that have not fallen out after the adult tooth has erupted.

OralVet Application - (Dental sealant that helps prevent bacteria and tartar build up)

ADDITIONAL INFORMATION - SPAY AND NEUTER SURGERY

Tattoo: l would like my pet to receive a small (1/2 inch) colored tattoo line near the spay or neuter incision for evidence the spay procedure has been performed (Can help prevent unnecessary future surgery). No cost.

Yes - please apply a spay tattoo.

No - I decline a spay tattoo.

For Spay (Ovariohysterectomy) Procedures Only:

If my pet is found to be pregnant:

l WOULD like the veterinarian to continue with the procedure.

l would NOT like the veterinarian to continue with the procedure.

If my pet is in heat (estrus):

I WOULD like to continue with the procedure, I understand there are increased risks of bleeding and other complication, and that an additional charge may be incurred for increased surgical time.

l would NOT like to continue with the procedure if possible

POST OPERATIVE CARE

Pain control:(Required)

I prefer giving oral tablet medications.

I prefer giving oral liquid medications.

I am unable to give any oral medications and prefer you give my Pet injection medications when possible.

Additional sedation:

I am concerned I may have difficulty keeping my pet calm after the procedure. I request additional sedatives to give if needed for the duration of recovery(likely about 14 days.)

The information provided on this form is true to the best of knowledge. I verify that I am the owner (or Authorized agent for the owner) of above named pet and authorize the above procedure to be performed. I authorize the use of anesthesia and other medications as deemed necessary by the veterinarian and understand the hospital personnel will be employed in the procedure(s) as directed by the veterinarian.

I have been advised as to the nature of this procedure to be performed and the risks involved. I understand also that there is always a risk associated with any anesthesia episode, even in apparently healthy animals and have discussed my concerns with the veterinarian. I understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated for the safety or care of my pet. I herby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian's professional judgement. I accept responsibility for any result in additional charges. I agree to be responsible for any charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital.

Client Signature(Required)

Date

Name

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

Surgery Consent Form

Pet Details

Owner Details

PATIENT MEDICAL HISTORY

PRE-ANESTHETIC TESTING

ADDITlONAL SERVICES

ADDITIONAL INFORMATION - SPAY AND NEUTER SURGERY

POST OPERATIVE CARE

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