Surgery Consent and Release Form in Glen Dale & Wheeling, WV | Wheeling Veterinary Associates/ Glen Dale Animal Hospital

SURGERY CONSENT AND RELEASE FORM

Please note: All pets entering Glen Dale Animal Hospital must be current on recommended vaccinations and free of external parasites. If your pet has not been a patient previously at our hospital, failure to provide documented proof of vaccination history may result in your pet being vaccinated. If external parasites are found on your pet during hospitalization, they will be treated at the owner’s expense.

Client's Name

First Last

Pet's Name

Procedure(s) to be performed

I authorize the Glen Dale Animal Hospital’s (also referred to as GDAH) veterinary staff to perform the abovementioned medical procedure(s) and /or treatment on my pet.

Initial

I have been informed of the risks and the benefits associated with performing the above medical procedure(s) on my pet. I acknowledge and understand that the above stated procedure(s) bear(s) certain known and unknown risks or unanticipated risks, which could result in injury to my pet, including, the possibility of death. I also understand and realize that additional risks of the procedure(s) may include adverse reactions to my pet, such as , but not limited to , allergic reactions from medications and/or complications presenting during(or after) surgery and anesthesia.

Initial

I Understand and agree that full payment to Glen Dale Animal Hospital is due upon completion of the surgical/medical treatment (including any related charges as herein described).

Initial

I certify that my pet has not eaten any food since midnight last night. However, If I am unsure whether my pet has had water or eaten anything today, I accept all responsibility for assuming the increased risk of complications that can arise from my pet’s aspiration (such as inhalation of regurgitated stomach contents) while under sedation, anesthesia, or while recovering from anesthesia- and do hereby agree to hold Glen Dale Animal Hospital and its agents, harmless from any and all liability associated with such increased risk for potential complications(including the possibility of death) to my pet.

Initial

We recommend that All Cats be tested for the Feline Leukemia Virus and Feline Immune-deficiency Virus. These are fatal, contagious diseases similar to human AIDS. We recommend all cats be tested for both diseases. I understand and would like to do the following.

I accept FELV and FIV testing - $44.41

I decline testing for FELV and FIV

Initial

We recommend that all dogs over the age of 6 months be tested for heartworm disease. Mosquitoes can infect dogs with this parasite, which can cause heart and lung damage, and eventually leading to death. I understand and would like to have my dog tested for heartworm disease.

I accept testing and preventative

I accept testing only - $27.00

I decline testing and preventative

Initial

We recommend that pre-anesthetic blood tests be performed prior to administration of anesthesia. These tests can help us detect anemia, dehydration, diabetes, kidney and liver disease. All of these conditions can contribute to complications with anesthesia and surgery. This testing is mandatory for all pets 8 years old and over. I understand and would like my pet to have the testing as an added method of safety.

I accept pre-anesthetic profile - $97.00

I accept general health profile -$ 147.50

I decline any blood testing

Initial

We recommend that an EKG be performed prior to anesthesia. An EKG is an electrical tracing of the heart's activity. EKG abnormalities may indicate that your pet is at risk of problems if they were to undergo anesthesia. This test is required in all instances of heart murmurs or heart disease, and is offered as an added precaution for safe anesthesia.

I accept EKG testing with Chest X-rays - $255.00

I decline EKG testing

Initial

We offer the HOME AGAIN pet microchip ID system. It is the most complete, nationwide system for recovering lost or stolen pets. It utilizes a tiny microchip which is implanted under the skin between your pet's shoulder blades. The microchip is encoded with a unique number assigned to your pet, which is registered with a national database. This number can be retrieved with a universal scanner by veterinarians and animal shelters, and you can be notified immediately. The procedure takes only seconds and is relatively painless, and can be done to all dogs and cats regardless of size, age or breed.

I would like my pet to be implanted with the HOME AGAIN microchip. - $42.00

I DO NOT wish to have this procedure on my pet.

Initial

Upon my signature below, I certify that: (1) I have read all of the above statements; (2) I understand and agree with the above statements, as shown by the presence of my initials alongside the statements; (3) I have been informed of the potential risks and benefits related to these medical procedures and treatment; (4) prior to signing this form, I have had all my questions answered and concerns addressed by the veterinarian, to my satisfaction and (5) I consent to the procedure(s) being performed on my pet.

Signature

Date

Telephone numbers where I may be contacted today: (Please provide at least two phone numbers, especially in case of an emergency.)

Phone 1

Phone 2

Phone 3

Name

This field is for validation purposes and should be left unchanged.