Surgery Consent Form

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

Pet Details

Pet Name(Required)
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Owner Details

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

Pre-Anesthetic Testing Safety Measures

Your pet will be under general anesthesia today. Because there is always the possibility that a physical exam alone will not identify all health concerns, we advise that a pre-anesthetic blood profile be completed prior to anesthesia. In order to best accommodate the needs of those patients 7 years of age or greater, a Basic Diagnostic Panel (or other applicable pre-anesthetic panel) will need to be completed within the last 6 months prior to the administration of any anesthetic medications.

It is important to understand that a pre-anesthetic profile does not guarantee the absence of anesthetic complications. It may, however, greatly reduce the risk of complications and identify medical conditions that could require medical treatment in the future.

Please select one of the below panels if this has not already been performed for your pet. The testing we advise for your pet is similar to and as important as those your own physician would run if you were to undergo anesthesia.

Pre-Anesthetic Panel Options:
NSVC Basic Diagnostic Panel: ($155)
Advised baseline panel for juvenile and early adult patients with no health concerns. Analyzes state of liver and kidney functions, and Complete Blood Count. In juvenile patients this is performed to identify concerns such as anemia or birth defects of the liver resulting in the poor function of these systems which may otherwise go undetected.

NSVC Diagnostic Plus Panel: ($175)
Advised complete panel for patients 7 years of age or greater OR any patient with health concerns. Includes all the tests above as well as Albumin (protein), Phosphorus (kidneys), Calcium (tumors), Total Bilirubin (liver), Amylase (pancreas), Cholesterol for additional analysis of internal organ function.

*Please note patients 7 years of age or greater who have not had a complete blood chemistry and CBC panel, such as above, in the past 6 months are required to choose one of the above panels.

*Heartworm tests, Felv/FIV combo tests, Glucose tests, basic panels for NSAID refills, Renal Panels and Cortisol tests are not considered a complete pre-anesthetic panel and one of the above options is still recommended and/or required.

Additional Services

I would like NSVC to perform the following treatments while my pet is in the hospital today:
Would you like to have your pet microchipped during this procedure? ($54)(Required)

For Spay (Ovariohysterectomy) Procedures Only

If my pet is found to be pregnant(Required)
SPAY TATTOO: Veterinarians use small, straight-line tattoos near the abdominal surgical incision line when pets are spayed to let future caregivers or shelters know that this particular pet no longer has internal reproductive organs. Discreet, painless tattoos can be performed after the surgery while the patient is under anesthesia. This can save your pet from future unnecessary surgery in the event they are lost or surrendered. We provide this service at no cost.
Would you like the Veterinarian to apply a tattoo near your pet's incision line to indicate they have been spayed at no cost today?

Emergency Life-Saving Measures

In the rare event that cardiac arrest occurs, would you like us to perform CPR? All attempts will be made to reach you, but knowing this ahead of time will allow us to act as quickly as possible.

Accept CPR - Please provide life-saving measures. I understand that the outcome of these measures is never guaranteed, and that an additional IS cost may be incurred (approximately $350-$650 for initial treatment).

Decline CPR - Please do not resuscitate.


If your pet is undergoing any type of soft tissue procedure today we will send you home with an e-collar to ensure the best possible post-op recovery. The doctor will fit them with the most medically appropriate type (soft or hard collar) as applicable to their surgical site but you may indicate if you have a preference to e-collar type.

If you already have an e-collar at home please bring it with you at the time of your discharge appointment and we will ensure it is still an appropriate fit.
Please select one:(Required)

Pre-Surgery Medical History

NOTE: Please answer the following question on the morning of your pet's surgery appointment.
Has your pet had an adverse reaction to a medication or previous anesthetic procedures?(Required)
Post-Operative Pain Control:(Required)
For many surgical procedures, the doctor will recommend limiting your pet's exercise for a period of time to aid in recovery. Your pet will be provided with post-operative pain medications to give at home, some of which may be somewhat sedating. If your pet is particularly energetic and you are concerned you may have trouble keeping your pet calm for the recovery period, we can provide an additional sedative for you to use as needed. The estimated additional cost for sedation medications is $15-$25.(Required)
If our records show your pet is not current on vaccines, would you like us to administer overdue vaccines today per doctor's recommendation?(Required)
Has your pet shown recent signs of illness such as vomiting, diarrhea, coughing or sneezing?
Has your pet shown changes in appetite, drinking or exercise habits?

General Anesthesia Consent

I verify that I am the owner (or authorized agent for the owner) of the above named pet. I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure as directed by the veterinarian.

I have been advised as to the nature of this procedure to be performed and the risks involved. No guarantees have been made regarding the outcome or cure. I understand that there is always a risk associated with any anesthetic event even in apparently healthy animals, and have discussed my concerns with the veterinarian. The veterinarian has provided me the opportunity to ask questions and receive answers regarding the procedure. This risk includes serious bodily injury or death. 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 hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian's professional judgment. I accept responsibility for any result in additional charges. I agree to be responsible for all 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.

I understand no staff will be attending to my pet overnight (pets needing special care may be referred to a 24 hour hospital).

In the event of an unforeseen emergency, we will attempt to reach you without delay. Please know that we will take every precaution to ensure that your pet is safe and healthy enough to undergo their procedure today. Any known risks will be discussed with you. However, very rarely, emergencies do happen and we want to know your preference if no one can be reached. Unless explicitly expressed we will proceed with extreme life-saving measures (CPR). You will be responsible for all charges incurred.

l 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 $30. (This policy protects your pet as well as others in the clinic).
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