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General Surgery Consent
General Surgery Consent
Surgical/Anesthetic Options: Please initial your choice for each option.
Laser Surgery: We have the ability to use a surgical laser rather than a scalpel blade for most routine procedures. This may decrease bleeding, swelling, and postoperative pain.
Required by veterinarian
I elect laser surgery for my pet (cost: $75.00)
I decline laser surgery
Therapeutic Laser Treatment: This treatment can be performed on your pet’s incision(s) postoperatively to reduce pain and aid in the healing process on a cellular level. (Not used on any growth removals)
I elect therapeutic laser treatment for my pet (cost: $13.50)
I decline therapeutic laser treatment
Microchip Permanent Identification: A microchip is a means of permanent identification that is implanted under the skin. If your pet is lost, your pet may be reconnected with you via the use of a chip scanner (most veterinary clinics, shelters and rescue organizations have one of these scanners).
I elect to have my pet microchipped (cost: $51.75)
I decline microchipping
E-Collar (Cone to keep the patient from licking):
Accept
Decline
Sedative to go home
Accept
Decline
Consent for Anesthesia/Sedation and Surgery
I, the undersigned, am the owner or authorized agent of the pet listed below, and am at least 18 years of age. I elect to
have this pet undergo the anesthetic and surgical procedure listed below, and declare that I understand the procedure along
with associated benefits and risks (up to and including death) as outlined above, and I have had the opportunity to have my
questions regarding the procedure answered.
Pet's Name
Date
MM slash DD slash YYYY
Species
Date of Birth
MM slash DD slash YYYY
Sex
Male
Female
Surgical Procedure(s):
The estimated price range for this procedure is between: $
Initial
Client Name:
(Required)
Phone number where you can be reached today:
(Required)
Would you like us to call or text you at this phone number?
Call
Text
Additional Services
My pet has had food withheld for a minimum of 8 hour:
Yes
No
List
My pet’s current medications/supplements:
Dose
Last given
Add
Remove
Veterinarian Name:
Veterinaria/Technician Signature:
Date
MM slash DD slash YYYY
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Comments
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920-722-1518
417 N. Tullar Road,
Neenah, WI 54956
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