Client Info

Contact Name *

First

Last

Contact Cell Phone Number *

Home Phone

Emergency Contact

Contact Email Address *

Pet Info

Pet Name *

Pet Species

Pet Breed

Other *

Pet Sex *

Procedure:

a at a

When was the last time your pet ate?

Date

Time

Does your pet have any current medical conditions (including coughing, sneezing, vomiting or diarrhea)? If yes, please describe:

Is your pet taking any daily medications? If yes, please describe:

For Dogs

Rabies and DAPP vaccines are REQUIRED with proof.

We offer these vaccines at a cost of: Rabies -$15.95; DAPP -$33.75.

Which vaccines would you like us to do today?

Would you like us to perform a Heartworm test on your pet? This test is highly recommended if not already done. This is offered at an additional cost of $39.95 *

Yes
No

Would you like for us to extract deciduous (baby) teeth? *

Yes
No

If any are found in your pet during an exam, Dr. Gaffrey will discuss this with you. This is an additional charge that ranges between $13.00 to $50.00.

For Cats

Would you like us to perform a Feline Leukemia Virus/FIV test? This test is an additional $50.25 *

Yes
No

Has your pet had the Rabies, FELV, or RCCP vaccine? *

Yes
No

If yes to the above question, please provide proof. **Rabies required**

We offer the vaccines at a cost of : Rabies - $15.95, FELV - $29.75, RCCP - $26.50

Which vaccines would you like us to do today?

If feline is a feral/stray would you like for us to tip the ear? Ear tipping involves removing the tip of the ear during surgery; it is a permanent visual indicator that the cat is fixed already. **Free of charge** *

Yes
No

For Cats and Dogs

Elizabeth collar (Cone)- Highly recommended as any licking or chewing of the incision after discharge that results in trauma to the surgery site will require extra care at your cost. This is an additional $23-$40. *

Yes
No

Pain medication at the time of surgery (both dogs and cats) and to go home (dogs only) is include.

Would you like us to insert a microchip into your pet today? In the event your pet gets lost, this chip can be scanned at any local pet store/vet office and will pop up with owner's and pet's information. This is an additional charge of $50.75 *

Yes
No

Would you like to have your pet to have Pre-anesthetic Bloodwork done? This checks to make sure organs are functioning properly along with your pet’s hydration status, anemia, infection, blood clotting abilities, etc. before putting your pet under anesthesia. This is an extra cost of $98.25 (This is REQUIRED for all pets over 5 years of age). *

Yes
No

CPR/DNR

In the event of unforeseen circumstances should your pet require cardiopulmonary resuscitation (CPR) including cardiac compression, positive pressure ventilation, emergency drugs and/or other intervention do you authorize us to provide life-saving measures? Costs of these services can be between $100-$300. If you choose to allow these procedures for your pet, we will try and contact you as soon as possible to inform you of the situation and discuss the options of how to proceed.

I request the staff of Stoneside Veterinary Hospital to perform CPR (Resuscitation) on my pet if my pet suffers respiratory or cardiac arrest.
I DO NOT want CPR performed on my pet. (DNR)

I certify that I am the owner, or authorized agent of the owner, of the above animal. I hereby consent to and authorize the doctors and staff at Stoneside Veterinary Hospital to admit this pet, perform the above-described procedures, and administer, medications, anesthesia, surgical procedures, tests and/or treatments that the doctors deem necessary for its health, safety and well-being while under their care and supervision. I have been advised of the nature of the procedures and the potential risks and benefits. I understand that veterinary medicine is an inexact science and that no guarantee of successful treatment can be made. I also understand that if fleas or ticks (or signs of these) are found on my pet, treatment will be administered at my cost.By signing, I acknowledge that I have read, understood and agree to all the terms listed above and on the reserve side of his form, and confirm that all the information given on this form is correct.

Today's Date *

Signature *

Clear Signature

Surgery Consent Form