Surgical Anesthesia Consent Form – Manchaca Village Veterinary Care.

Surgical Anesthesia Consent

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 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 fleas and/or $22 for ticks)
Spays and Neuters ONLY
- I understand that complication fees will be incurred if my pet has the following conditions prior to surgery: FEMALES: Estrus ($46.93), Early Pregnancy ($46.93) or MALES: Cryptorchid ($105.13)
Dental Procedures ONLY
- I AUTHORIZE dental x-rays (if deemed necessary by the attending veterinarian)
- I DECLINE dental x-rays. (Please note, 2/3 of the tooth is below the gum line, and requires x-rays for a thorough check)
- 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:
Laser Surgery
- I have been told about the option of precision laser surgery and its benefits to my pet, and authorize its use during the procedure(s) listed above. The additional cost for this service is $67.24.
- NO, thank you.
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 $37.
- NO, thank you.

Surgical Anesthesia Consent

Consent

Choose all that apply:

Optional services. Choose all that apply:

Manchaca Village Veterinary Care

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