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Surgery Consent Form

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Surgery Consent Form

Thank you for entrusting Cypress Veterinary Clinic for your pet’s care!
Please fill out our surgery consent form in its entirety.

Name *

First

Last

Email *

Pet's Name *

Procedure your pet is receiving *

When was the pet's last meal? *

Is your pet on any medications? *

If yes, what medications and when were they last given? *

Is there anything else needed while pet is under anesthesia? (check all that apply)

Courtesy Nail Trim
Heartworm test
FeLV/FIV testing
Check ears
Clean ears
Express anal glands
Fecal testing
Update vaccines if possible (Dr. Discretion)
Microchip
Pre-anesthetic blood work
Biopsy
Refill of preventions
Other

Please specify other service *

CPR in animals, like in humans, is a life-saving procedure that uses medications, artificial breathing and chest compressions. This is to help revive the pet when they stop breathing on their own and/or their heart stops beating.

CPR Consent *

I DO want CPR performed on my pet if my pet goes into respiratory or cardiac arrest.
I DO NOT want CPR performed on my pet if my pet goes into respiratory or cardiac arrest.

Emergency Phone Number *

Secondary Emergency Phone Number

While undergoing these procedures your pet will receive anesthetic drugs that prevent pain. Because we care about your pet’s comfort and strongly believe that pain relief is important, additional pain medications will be provided, as needed, to control the level of your pet’s discomfort after surgery and during its recovery.

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

I understand that there may be restrictions to my pet’s activity and agree to follow the recommended post-operative instructions after this procedure. *

I have read and understand

I understand that CVC recommends current blood work (4 weeks or less) for any procedure requiring anesthesia regardless of age. *

I have read and understand

I am the owner (or authorized agent of the owner) of the animal described above, and have the authority to execute this consent. 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. *

I have read and understand

Today's Date *

Phone

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Address

753 West Cypress Street
Kennett Square, PA 19348

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Contact

E: [email protected]
P: 1-484-734-0686

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Hours

Mon, Tues, Wed, Fri: 8 am – 6 pm
Thurs: 8 am – 5 pm
Sat & Sun: Closed

Name *

First

Last

Email *

Phone

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