Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Pet's Name *

Species *

Dog
Cat
Other

If other, please specify *

Breed *

Color

Species *

Male
Male (neutered)
Female
Female (spayed)

Age/Date of Birth *

Surgical Procedure *

I have also been informed that there are certain risks and complications, including death, associated with any operation or procedure of this type. I further understand that during the course of the operations or procedures, unforeseen conditions may arise that may necessitate the performance of additional procedures.

Blood Work

Basic anesthesia charges include an initial physical exam, pre-anesthetic assessment of anemia or kidney disease, and monitoring of cardiac function during anesthesia. I understand that underlying disease may increase anesthetic risk, especially in animals over five years of age or in ill animals. The doctor’s choice of anesthetic medications may be altered accordingly if pre-existing problems are known. Pre-anesthetic blood work will be run in order to determine if surgery will be performed to help to alert the doctor to these conditions. As the responsible owner/party, I understand these conditions.

Microchip

We offer identification microchips, which can be injected while your pet is under anesthesia. The benefit of having your pet chipped is permanent identification for the life of your pet. Your pet will have a one-of-a-kind number that is specific to only to them.

Microchip - We offer identification microchips, which can be injected while your pet is under anesthesia. The benefit of having your pet chipped is permanent identification for the life of your pet. Your pet will have a one-of-a-kind number that is specific to only to them. *

I authorize my pet to be microchipped while under anesthesia at a cost of $49.00
I decline my pet to be microchipped while under anesthesia at a cost of $49.00

“Living Will” Clause - In the event of life-threatening complications, do you authorize the use of measures to revive your pet? *

I authorize
I decline

Dental Extractions - If your pet is having any dental procedures today, there is always a possibility they will need extractions. The doctor will examine all teeth while your pet is under anesthesia and determine which, if any, teeth will require extraction. Simple or complex extractions may be necessary at an additional cost. *

I authorize dental extractions
I decline dental extractions
Does not apply to my pet

Pain Control Clause - I understand that surgical procedures result in pain. The doctors and staff of Bocage Animal Hospital strongly recommend postoperative pain medications. I understand that no medication will completely relieve pain. The doctor will prescribe the medication he/she feels is best for your pet. *

I authorize pain medication to be prescribed for my pet
I decline pain medication to be prescribed for my pet

I am the owner or the agent for the owner for the animal described above, and I have the authority to execute this consent.

Signature *

Date *

Surgery Waiver

Please complete this form before your next visit.

Location

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Hours