Surgery Consent Form ProceeduresSurgery Authorisation I hereby certify that I am the owner of the above-named animal or am responsible for it and have the authority to execute this consent. I hereby authorise the performance of the following procedure(s):Social MediaDo you give permission for us to take and publish photos & videos of your pet on media platforms? Yes No Social Media Handle What is your social media handle (so we can tag you)? Patient ID Patient ID as supplied by surgery Pet Name Your pets' name: Species Your pets' species: Age Your pets' age: Weight Your pets' weight: Your Contact Email(Required) Your best contact email Enter Email Confirm Email Your Name(Required) Your Name: First Last Date(Required) DD slash MM slash YYYY Preventitives THIS SECTION OF THE CONSENT PROCESS REFERS TO ADDITIONAL COMPONENTS TO THE PROCEDURE. Is your pet due for any preventatives? (Please select Yes or No): Heart Worm? Yes No Vacc Vacc? Yes No Flea & Tick Flea & Tick? Yes No Prevention Pack Would you like a prevention pack with 12 months flea and intestinal worm prevention for a 20% discount? Yes No Estimated Cost I understand that the full balance of the invoice must be settled ON DISCHARGE. The estimated cost I have been given is between: Deposit Amount Deposit Payment All procedures require a deposit to be paid prior to surgery. The deposit is equal to 50% of the upper limit of the total bill estimate with the exception of dental procedures, which will require a $599 deposit. The deposit amount will be allocated to your account and will be applied to the total cost of your bill upon being invoiced. Any unpaid amounts on your account are required to be settled upon discharge of the patient. Authorisation(Required) I AGREE TO PAY THE OUTLINED DEPOSIT ON THIS FORM UPFRONT AND UNDERSTAND THAT THE FULL BALANCE OF THE INVOIICE MUST BE SETTLED ON DISCHARGE. I hereby also authorise the use of such anaesthetics as you deem advisable and performance of such surgical or therapeutic procedures as you determine to be indicated. I understand that there is a risk with every general anaesthetic, and I have had any and all concerns regarding this procedure answered satisfactorily by a veterinarian from this clinic. I have been advised that the procedure to be performed is available in some licensed veterinary premises should I have that preference. I understand that the scheduled procedure will be carried out using human medical equipment and includes practitioners, though a veterinarian from SCVC will be present to render veterinary care during the procedure. The diagnostics related to the procedure will involve veterinary and human medical opinion, which are intended to optimise the cumulative medical knowledge about treatment opinions for my pet. I consider this to be an adequate reason to depart from the utilising of licensed veterinary facilities for this procedure. Please sign below: Blood Test We recommend having a pre-surgical blood profile run on your animal. These blood tests help us to assess the health status of your pet more completely and determine if there are any additional precautions we need to take before the anaesthetic. No thank you Blood Test Please @ $148 Collar We recommend all surgery patients go home with a collar to prevent licking and self-trauma of the incision. No collar thank you Basic Elizabethan Collar @ $17.50 Premium Cushi Collar @ $42.90 Anti-nausea As part of our standards of care, we recommend routine administration of Cerenia (anti-nausea injection to prevent pre and post operative vomitting) No Anti-nausea Anti-nausea Please @ $38.50 Total Payment Today: Total Payment Today: Credit Card(Required) Pay With Credit Card:Card Details Cardholder Name PhoneThis field is for validation purposes and should be left unchanged.
