Surgery/procedure consent form

Your Name*

First Last

Pet's Name*

First

Phone*

Have you noticed vomiting/diarrhea/coughing/sneezing or wheezing in the last 7 days?*

Yes
No

Please list all medications your pet is on: Name, frequency, last dose given? List each medication.

Does your pet have a history of allergic reaction or difficulty following anesthesia?*

Yes
No
Unsure/Never been under anesthesia

When was your pet's last heat (female pets only)?

Every pet needs to be microchipped in case of loss, being startled or stolen. Doing that during surgery is a great time to ensure pain free experience. Please choose below if you would like your pet to be microchipped with a T-CHIP (temperature reading chip)*

Yes
No

For more information about the temperature microchip, please copy and paste this link into a new browser window: https://partner.24petwatch.com/Shelter_Vet/t-chip.aspx

Are there any other concerns or questions you have for the veterinarian?

Consent*

I agree to CPR being performed in case of arrest
I elect a “Do Not Resuscitate” status in case of arrest

Please note, we must ask this question for safety reasons. We absolutely do not anticipate any anesthetic problems, but we need to know in the unlikelihood we are faced with this situation. Basic CPR is always performed as part of our anesthetic protocols, but if you would like us to go above and beyond, you must acknowledge that certain fees will apply (approximately $600). If you are not able to be contacted immediately, resuscitation efforts will be continued to be performed at the doctor’s discretion. If you cannot be reached by phone within 20 minutes of CPR being initiated and your pet is unable to support cardiac or respiratory function on their own, I authorize the doctor on duty to make the best decision (considering quality of life) to discontinue CPR which may result in my pet's death.

Surgery/Procedure Treatment Plan Estimate - Were you provided with a written estimate of the cost of the procedure?*

Yes
No, Please Provide Me With a Copy

Agreement*

I agree

By submitting this form, you agree you have read and understood all parts, are the authorized person to make this decision (lawful owner), and you agree to pay Trenton Pet Hospital for the services provided.

Surgery/Procedure Consent Form

Address

Business Hours

Contact Info