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12117 Manchaca Rd., Austin, TX 78748
512-VET-CARE / 512-838-2273
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Surgery Consent Form
Surgery Consent Form
Pet's Name
*
Owner's Name
*
First
Last
As owner (or agent for the owner) of the pet mentioned above, I give consent to MANCHACA VILLAGE VETERINARY CARE ("MVVC") to perform the following procedures: (check all that apply)
Spay
Neuter
Dental Cleaning
Extractions
Lump Removal
Other: (please describe)
Consent
By initialing below, I authorize MVVC to perform emergency, anesthetic, or surgical procedures that may be necessary for treating and maintaining my pet’s well being. While I expect all procedures to be performed to the best of the staff’s ability, I realize the hospital makes no guarantee or warranty regarding the results. If my animal should injure itself, escape, fail to eat, become ill or die, I will not hold MVVC or it’s employees responsible. I expect the use of reasonable precautions to ensure my pet’s safety, and I agree to pay in full when the pet is discharged.
By initialing here, I acknowledge that the surgical risks have been explained to me.
*
Choose how you would like to be reached TODAY
*
Call Me
Text Me
Call or Text me at THIS number
*
I am available to pick up my pet:
*
Anytime
After 10am
After 11am
After 12pm
After 1pm
After 2pm
After 3pm
After 4pm
Choose all that apply:
Please Check:
*
I am aware that my pet may be shaved to allow IV Catheter placement and venous access.
Please Check:
*
I am aware that each and every admitted pet is checked for fleas and ticks. If fleas or ticks are found, a flea/tick treatment will be given to my pet ($9.45 fleas and/or $23.74-36.72 for ticks, depending on weight)
Spays and Neuters ONLY
I understand that complication fees will be incurred if my pet has the following conditions prior to surgery: FEMALES: Estrus/Early Pregnancy ($73.50) or MALES: Cryptorchid ($126)
Dental Procedures ONLY
I understand all extractions or other corrective measures will be performed at a later date unless previously discussed and approved in writing. Any abnormalities found on x-rays will be discussed at time of patient discharge with the veterinarian.
Optional services. Choose all that apply:
HomeAgain™ Microchip Implant Consent
I have been told about the benefits of Microchips for lost pets, and how it works. YES, I would like to have a microchip implanted in my pet while he or she is under anesthesia. I choose the discounted package (Microchip, Implantation and Chip Registration) for $52.75.
NO, thank you.
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Meet with a doctor for an initial exam.
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