Surgery Consent Form – Chester Valley Veterinary Hospital

Your name *

First

Last

Primary Contact Phone Number For Day of Surgery *

Email *

Pet's name *

Pet's breed

Pet's date of birth (estimated is okay)

Single reason for visit *

Medical History

Is your pet experiencing excessive thirst? *

Yes
No

How long has this been happening? *

Is your pet drooling excessively? *

Yes
No

How long? *

Is your pet lethargic? *

Yes
No

How long? *

Is your pet eating/drinking well? *

Yes
No

How long? *

Is your pet experiencing pain? *

Yes
No

How long? pain *

Does your pet have any wounds? *

Yes
No

Where? *

When did it happen? *

Is your pet panting excessively/experiencing labored breathing? *

Yes
No

How long? *

Is your pet experiencing labored breathing/wheezing? *

Yes
No

How long? *

Is your pet sneezing/coughing/hacking? *

Yes
No

How long? *

Is your pet experiencing any hair loss? *

Yes
No

How long? *

Where? *

Has your pet experienced weight gain/loss? *

Yes
No

How long? *

Does your pet have foul breath? *

Yes
No

How long? *

Is your pet experiencing difficulty urinating? *

Yes
No

How long? *

Is your pet experiencing excessive urination? *

Yes
No

How long? *

Have there been any changes in urine (color/odor)? *

Yes
No

How long? *

Is your CAT urinating outside of the litter box? *

Yes
No
Not Applicable

How long? *

Is your DOG urinating inappropriately (having accidents inside the house)? *

Yes
No
Not Applicable

How long? *

Does your pet have dirty/smelly ears? *

Yes
No

How long? *

Is your pet scratching their ears and/or shaking their head? *

Yes
No

How long? *

Is your pet experiencing eye discharge? *

Yes
No

How long? *

Is your pet squinting? *

Yes
No

How long? *

Is your pet vomiting (food/water/yellow bile)? *

Yes
No

How long? *

How many times per day/week/month *

Is your pet having diarrhea (liquid/soft/bloody)? *

Yes
No

How long? *

How many times per day/week/month *

Is your pet experiencing any lameness/limping? *

Yes
No

How long? *

Does your pet have any new or unusual lumps? *

Yes
No

Where? *

How long? *

You qualify for a "Wellness" appointment.

You qualify for a "Sick/Urgent Care" appointment.

Rabies Vaccination Verification

Is your pet's Rabies vaccination current? *

Yes
No

*Proof of current Rabies must be on-file with Chester Valley Veterinary Hospital. If you are unsure of your pet's Rabies status, let the staff know and we can help!

Additional Information

Is your pet taking any supplements or medications?

Has your pet been given any medication in the last two to four weeks?

Yes
No

When were the medications last given?

Has your pet been seen at any other clinics since your last visit at Chester Valley Veterinary Hospital? If so, please indicate which hospital (PET ER, Midnight Sun Animal Hospital, VETCO, or any other veterinary medical facility) *

Yes
No

Hospital Name *

Do you feel that your pet may bite or injure a staff member while at the vet? Please let us know so that we can keep all staff and animals safe. *

Yes
No

Do you have any physical limitations that would cause you to be unable to handle your pet inside the clinic? Please let us know so we can have staff prepared to help. *

Yes
No

If your pet is aggressive or reactive to people and/or other animals please keep them in your vehicle until you have checked in and your technician is ready to bring you and your pet directly into an exam room.

Surgical Consent

I acknowledge that my pet is scheduled for an anesthetic procedure. I have been informed that advances in anesthesia and anesthetic monitoring techniques have made routine procedures relatively safe, with low rates of complications. However, I understand that occasionally problems can occur due to pre-existing conditions that are not evident during routine histories and physical examinations. I understand that some risk always exists with anesthesia, even in apparently healthy animals, including the possibility of death. I have discussed my concerns with the veterinarian and understand that it may be necessary to provide additional medical or surgical treatment to my pet in the event of unforeseen circumstances. I realize that no guarantee, legal or ethical, can be made to me regarding the outcome of any procedure performed. I hereby authorize the use of anesthetics and other medications, as well as any such additional treatment, as deemed necessary by the veterinarian. I understand that hospital personnel will be employed in treating my pet. I have carefully read, and fully understand, this consent. The fees associated with these services have been explained to me, and I agree to pay such fees at the time my pet is released from the hospital. *

I have read and agree.

To minimize problems the doctors and staff at Chester Valley Veterinary Hospital have recommended that my pet be screened prior to anesthesia. *

I Consent to the recommended pre-anesthetic diagnostics.
I Decline to the above recommended pre-anesthetic diagnostic.

Please be aware that if your pet is geriatric (over 10 years of age) preanesthetic bloodwork is mandatory for the anesthetic safety of your pet.

I hereby certify that I am the owner or authorized agent of the above-named animal and have the authority to execute this consent. *

I have read and certify.

Digital signature *

Date *