Surgery Form

Today's Date(Required)

MM slash DD slash YYYY

Owner’s Name(Required)

First

Last

Phone Number(s) where you can be reached TODAY #(Required)

Pet’s Name(Required)

Is your pet on any medications at this time? If so, please list all medications and frequency given

Is your pet allergic to anything? If so, please describe

Has your pet had any illness or seizures in the past? If so, please describe

Has your pet been given any food or medications today?(Required)

Yes

If your pet needs to be given any medications at home, which to you prefer to give?(Required)

Liquid

Tablets

Reason for Surgery(Required)

Spay or Neuter surgery

Microchip Identification with a surgical procedure

Remove Baby (deciduous teeth)

Dental Cleaning with or without necessary tooth extractions

Mass or Tumor Removal

Other procedures to be performed, as discussed with a doctor

Check all that apply

Other procedures(Required)

Would you like to have any of the following services updated while your pet is in our care today?

Heartworm test

Fecal evaluation

Anal Gland Expression

Authorization and Consent for Anesthesia/Surgery:

Financial Consent(Required)

I have been given a financial estimate for the services my pet will receive, and agree to payment at the time the services are performed.(Required)

Risks Consent(Required)

I understand that there are inherent risks with anesthetizing my pet, that complications and adverse reactions can arise, including, in some cases, death. Veterinary Clinic of Myrtle Beach’s Doctors and trained staff members will take proper precautions to minimize these risks and make the procedure as safe as possible. I am the rightful owner of the pet named above, I understand the risks of the procedure, and give my consent.(Required)

Owner's Signature(Required)

IN THE EVENT OF A MEDICAL CRISIS:

In case of CPR needed:(Required)

I wish for the doctors of the Veterinary Clinic of Myrtle Beach to perform CPR on my pet if he/she suffers respiratory or cardiac arrest. I understand that my pet may or may not respond to this life-saving procedure. I understand that if my pet survives because of CPR, he/she may have permanent health issues. CPR may cost up to or more than $300.00

I DO NOT want CPR performed on my pet. I understand that if my pet stops breathing, and/or his/her heart stops beating, that my pet will die. I elect to have DNR orders placed on my pet’s record for his/her boarding stay.

Signature(Required)

Date

MM slash DD slash YYYY

This field is for validation purposes and should be left unchanged.