Surgery Form

Save time at your pet’s surgery. Complete your required surgery form online before your visit.

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Surgery Form

Please fill out this form as completely and accurately as possible so we can best prepare for your pet’s procedure.

Owners Name *

Date *

Email *

Pets Name: *

Procedure To Be Performed *

ALL VACCINATIONS MUST BE CURRENT - PROOF IS REQUIRED

I understand that in performing the above procedure/surgery my pet will receive a general anesthetic. I understand that some risk of injury or death always exists with anesthesia and/or surgery and I am encouraged to discuss any concerns I have about those risks with my veterinarian before the procedure is initiated. We offer several options to minimize surgical complications and increase your pet's comfort, both during surgery and recovery

ALL ITEMS LISTED BELOW ARE PTIONAL AND WILL COST MORE

Please initial in either the YES or NO column

Preanesthetic bloodwork ($125.00) - Bloodwork is required for patients 7 years and older. Allows assessment of organ function and evaluation of underlying diseases (diabetes, kidney dysfunction, liver dysfunction) that may increase your pet's anesthetic risks and complicate recovery. *

Post-operative laser therapy ($20.00) - Laser therapy is a painless procedure that will stimulate tissue healing, decrease post-operative pain and decrease recovery time for your pet. *

Home Again Microchip ($45.00) - Prepare for a disaster. Very few pets find their way home without permanent identification. Microchipping provides peace of mind that if your pet is ever lost, he/she has a permanent, lifetime ID implanted in them so they can be linked to you and get back home. *

Please initial in appropriate area

Your pet will receive an IV catheter and fluids during surgery. This allows us to keep patients hydrated and to maintain blood pressure during surgery. Catheterization gives quick venous access in the event of anesthetic complications. *

To maximize comfort, your pet will receive pain medication following surgery. I understand that I am responsible for any costs associated with pain management for my pet. *

I acknowledge that my pet will be going home with an Elizabethan collar (E-Collar) to protect my pet from damaging his/her incision. In addition to restricting my pet's physical activity, the E collar must remain on my pet (except for eating) for 10-14 days. I agree to monitor my pet closely to ensure that he/she does not find a way to damage this incision. Failure to follow discharge instructions could result in self-inflicted injuries to my pet due to excessive movement, licking, biting, or otherwise damage to the incision or treatment area. Roland Veterinary Clinic is not responsible for costs incurred for failure to follow instructions. *

I understand that if my pet has fleas, ticks, or other parasites he/she will be treated at my expense. This is to ensure the safety of all patients at Roland Veterinary Clinic. *

Payment is due in full at the time that services are rendered. Your pet will be boarded until payment is received in full. (Canine boarding is $25 per day, Feline boarding is $15 per day) *

If your pet is here for dental cleaning, extractions may be necessary to ensure your pets comfort and dental health. Extractions are NOT included in the cost of a dental cleaning. Please initial the appropriate choice below concerning extractions.

I give permission for the doctor to perform extractions as needed. *

Please call to discuss extractions before performing the procedure. *

Acknowledgement and Consent of Surgical Risks

I do hereby authorize Roland Veterinary Clinic to perform a procedure requiring general anesthesia on my pet. I understand that during the performance of this procedure, unforeseen conditions may be revealed that may necessitate an extension or variance in the planned procure. I am aware of the risks and release Dr. Garth Robinson DVM and/or Dr. Katelyn Roth DVM, and/or Dr. Erin Goar, DVM, or any trained/certified employee of Roland Veterinary Clinic from any legal or financial responsibilities from anesthetic complications.

My signature on this form indicates that any questions I have regarding the procedure, recovery, or potential complications have been answered to my satisfaction.

Signature

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Date *

Phone *

Phone

Surgery Form

Surgery Form

ALL VACCINATIONS MUST BE CURRENT - PROOF IS REQUIRED

ALL ITEMS LISTED BELOW ARE PTIONAL AND WILL COST MORE

Please initial in either the YES or NO column

Please initial in appropriate area

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Proudly Serving the Pets of Roland, IA, and Beyond

Big or small

Proudly Serving the Pets of Roland, IA and Beyond

Big or small

Proudly Serving the Pets of Roland, IA and Beyond

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