Owner Name *

First

Last

Phone *

Email *

Pet Name *

First

Last

Sex *

Male
Female

Age

Selected Value: 0

Date of Surgery *

Procedure *

Vaccines

Rabies vaccination must be current or updated at time of surgery.

If your pet is on any medications, when was the last dose and what medication

If external parasites - fleas or ticks are detected upon exam today, treatment products will be applied at additional charges. Has your pet been treated at home? What product and when

If your pet is to be spayed and is found to be pregnant, Do you authorize termination of pregnancy at additional charges

Please check off the recommendations you would like at additional charges

Feline Leukemia/Feline Immuno-Virus/Heartworm Test - This tests for those viruses & heartworm infection $63.00
Pre-Surgical Blood Analysis/CBC - This is to ensure vital organs are functioning in a healthy and normal manner before administering anesthesia. $118.00
IV Catheterization -This is performed prior to surgery; provides immediate access to administer fluid therapy and/or emergency drugs, should the need arise. $43.00
Home Again Microchipping - $62.00 Already Microchipped? If yes, we can scan your pet to confirm the number
E-Collar - Prevents your pet from licking or chewing at the surgery site. $16.50
DeWormer - Would you like us to get a treatment of intestinal parasite control ready for you? Price depends on Doctors pre surgical exam & treatment.
Fecal Lab Exam - Laboratory Test for intestinal parasites $49.00

I have been advised of the nature of the services and procedures to be performed. I understand that there is always risk associated with any anesthesia episode, even in apparently healthy animals. As the owner or agent of the animal named above, I hereby give my consent to Grantsburg Animal Hospital/Wild River Veterinary Clinic to perform the following procedures and or treatments. I realize that I am responsible for payment in full at the time of discharge. *

Signature

Surgery Consent Form

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