Pet Name *

Pet Age *

Pet Weight *

Owner Name *

Phone Number *

Email *

Please list any concerns with your pet that the doctor would need to examine or treat while here: *

Pre-anesthetic Blood Testing *

Our greatest concern is the well-being of your pet. We will perform a brief physical exam before administering anesthesia. However, disorders of the liver, kidneys, and blood are not detected without blood tests and may increase anesthetic risk. Therefore, we highly recommend pre-anesthetic blood screens. Blood work is required on pets 5 years of age and older.

Estimated cost: $143 (Chem10 + CBC in-house)

Intravenous Catheter and Fluid Administration

Fluids given thru an intravenous catheter during surgery help maintain normal blood pressure and allow rapid administration of drugs should an emergency situation develop. An intravenous catheter and fluid administration will be performed on all patient's receiving surgery as per our practice protocol.

Pain Medications

In order to serve the comfort of our patients, post-surgical pain and anti-inflammatory medications are prescribed. Certain procedures and patients may require additional pain management in the form of injections during and following surgery. Any pain medication is at an additional cost and varies depending on your pet's weight. Estimates are available upon request.

Incidental Findings

I understand my veterinarian may discover other or different conditions (i.e. fleas, ear infections, etc) which require additional or different procedures and/or treatments than those planned. I authorize the veterinarian to perform such other procedures which are deemed necessary in their judgement.

Please select a response for each of the following:

Nails (complimentary) *

Yes
No
If Needed

Teeth Extractions

Yes
No
If Needed

If your pet is having a dental procedure today, are you okay with extractions that the doctor deems necessary for your pet's health?

Microchip Implantation *

Yes
No
If Needed

Biopsy (if tumor excised) *

Yes
No
If Needed

Current on Vaccines *

Additional Bloodwork *

Carrier/Personal Items *

Authorization to perform surgery/treatment *

Clear Signature

I hereby authorize Animal Health Care Center of Hershey to perform such diagnostic, therapeutic, or surgical procedures as prescribed above under anesthesia. The nature of such services has been described to me to my satisfaction and I realize that no guarantee or warranty can ethically and professionally be made regarding the results or cure. All surgical procedures involve some risks, up to and including anesthetic complications or death. I also authorize the staff in an emergency situation, to follow through with such procedures as necessary for the well-being of my pet until further communication with me. I understand the above and I assume financial responsibility for all services rendered.

Surgery Consent Form