Surgical Authorization and Option Consent Form

COUNTRYSIDE VETERINARY HOSPITAL

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Surgical Authorization and Option Consent Form

* Indicates required field

Name *

First

Last

PET NAME *

PHONE NUMBER *

DATE *

LASER SURGERY OPTION

The LASER produces little or no blood loss for your pet because the LASER seals the small blood vessels.
The LASER produces little or no swelling at the surgical site because the LASER seals the lymphatic vessels.
The LASER produces less post operative pain for your pet because the LASER seals the nerve endings.
The LASER allow very precise removal of tissue

NOTE: Some surgeries are only performed with the laser

I understand that LASER surgery is an option for my pet and I have been advised of the advantages this procedure will offer. *

YES I understand the benefits and I want my pet to have LASER surgery at the addiotional cost of $57.50 NO I do not want my pet to have LASER surgery – use scalpel and scissors

BLOOD TEST OPTION

Any time your pet is to be put under a general anesthesia we recommend a pre-anesthetic blood screen. The blood screen checks out your pet’s liver and kidney function and helps us to determine if it is safe for your pet to undergo anesthesia, the type of anesthesia used and whether fluids would be beneficial to support the kidneys during the procedure. (NOTE: The additional cost for this test is $86.00)

WOULD YOU LIKE BLOODWORK RAN ON YOUR PET? *

YES please complete the recommended blood tests prior to anesthesia NO I decline the recommended blood tests

MICROCHIP OPTION

We can now microchip your pet for the purpose of permanent identification. Microchips save lives. We strongly recommend implanting microchips in case your pet is lost or stolen. Since this is a permanent identification, your pet can never lose, alter or damage the microchip. Animal shelters and veterinary hospitals locally and nationwide routinely scan pets that they receive for microchip identification. (NOTE: The additional cost for the microchip is $56.00 and includes the registration/ fee with Home Again)

DO YOU WANT US TO IMPLANT A MICROCHIP IN YOUR PET? *

YES please implant my pet with a microchip NO do not implant a microchip ID in my pet

ADD FLUIDS

DO YOU WANT US TO ADD FLUIDS *

YES Please give my pet IV fluids (NOTE: The additional cost is $36.00) NO Do not give my pet IV fluids

DENTAL OPTIONS

1. IF EXTRACTIONS ARE RECOMMENDED BY THE VETERINARIAN *

Perform whatever procedure is required Telephone me before any procedures are performed

2. IF I CANNOT BE REACHED BY PHONE *

Perform whatever procedure is required Do only what I have authorized

IF MY PET IS HAVING A SON-SEDATED DENTAL AND A SEDATED DENTAL IS RECOMMENDED *

Perform the fully sedated dental Telephone me before any changes in procedure

DENTAL XRAYS *

YES Please take dental x-rays (NOTE: Additional cost is $25.00 to $120.00) NO Please do not take dental x-rays

SURGICAL CONSENT

I am the owner or agent of the above-described animal and have the authority to exercise this consent.
I hereby consent and authorize the performance of the procedures as discussed.

I authorize and consent to the use of anesthetics, sedatives, medications and/or procedures, as the veterinarian deems appropriate. If during the performance of these procedures an unforeseen condition is revealed, I further authorize and consent for the veterinarian to use their best judgment in the matter of my pet’s health.

I understand there is always some risk associated with the use of anesthetics, sedatives, medications and surgery. I also understand that my pet may have unforeseen conditions that may result in complications or even death.

I have been advised as to the nature of the recommended procedure(s) and/or operation(s) and the risks involved. I realize that results cannot be guaranteed.

SURGICAL CONSENT *

I CONSENT

Submit

Get In Touch

Countryside Veterinary Hospital
Address: 3120 S Woodruff Ave
Idaho Falls, ID 83404
Main Phone: 208-522-8010
Email: countryside.idahofalls@gmail.com

Countryside Pet Center (boarding)
Phone: 208-522-9011

Office Hours

Monday: 7:30 am to 6:00pm
Tuesday: 7:30 am to 6:00pm
Wednesday: 7:30 am to 6:00pm
Thursday: 7:30 am to 6:00pm
Friday: 7:30 am to 6:00pm
Saturday: Closed
Sunday: Closed

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