SURGERY CONSENT FORM First Name* Last Name* Telephone Number* Email* Pet's Name* Surgery or Procedure* Please SelectNeuter (male)Spay (female)DentalLump RemovalBroken Nail RemovalDewclaw RemovalCT - ScanOtherI’m not sure Please Select*SurgicalLaparoscopic - minimally invasiveNot sure surgical or laparoscopic If needed, I hereby authorize to extract diseased teeth and perform dental x-rays*YesNoNot sure Specify the location* Submit for histopathology*YesNoNot Sure Specify which nail* Please choose* Front DewclawsBack Dewclaws Please fill in* Please add the following Nail trimMicrochipAnal glands expressionHeartworm Test (dogs only)Leukemia and FIV test (cats only)E-CollarClean earsVaccinesOther Please Specify* ANESTHESIA RISK Please read carefully and check mark all the boxes All surgeries and the use of anesthetics and drugs present some risk of complications possibly including injury or death. The surgery performed is a major surgery. Every reasonable precaution and the best possible medical care will be exercised. Wellness Veterinary Clinic does not provide 24 hours supervision as in an emergency facility. Overnight stay is without supervision after the clinic is closed. No advanced diagnostics will be performed prior to surgery. Some medical conditions, which may increase the patient's risk and may not be detected without such testing. Would you like us to perform bloodwork before the procedure?* YesNo Consent form and waiver: I hereby request that Wellness Veterinary Clinic provide the service for my animal. I agree to waive any or all claims against Wellness Veterinary Clinic in the event of injury,complications, or death of my animal. I have read, understand and agree to follow all aftercare instructions provided by Wellness Veterinary Clinic. I will seek the care of a veterinarian for any suspected post surgical complications and bear full financial responsibility for any expenses incurred. I hereby declare under penalty of perjury that I am the owner (or authorized agent) of the above described animal(s) and that I have not withheld any information regarding known pre-existing medical conditions. Signature
