Date *

Client's Name *

First

Last

Patient's Name *

Type of surgery being performed *

I, the undersigned, do hereby certify that I am the owner (or a duly authorized agent for the owner) of the pet named above. I consent and authorize Robertson County Animal Clinic (RCAC) to hospitalize, administer vaccines, medications, and anesthetics; and perform tests and surgical procedures that the doctors deem necessary for the health, safety, and well-being of the patient while at RCAC.

The nature of the treatments and procedures has been explained to my satisfaction. I realize that no guarantee can ethically or professionally be made regarding the results, cure, or outcome.

I understand that I, the undersigned, assume financial responsibility for all services rendered and that payment in full is due at the time services are performed.

Should I not pay in full and my account becomes delinquent, I also understand that I am responsible for any collection fees incurred.

Signature *

Clear Signature

Phone *

Email *

Alternate Contact Name *

First

Last

Alternate Contact Phone *

Medical History

The following services are not included in the base surgery prices. Please let us know if you would like an estimate before your pet's procedure.

Has your pet had any coughing, sneezing, vomiting, diarrhea or other health issues we are not aware of in the last 10 days? *

Yes
No

If yes, please explain *

We require that all dogs are up to date on Rabies and Bordetella (kennel cough) vaccines and cats must be up to date on Rabies to stay for surgery. If they are not up to date in our records, you must provide proof of vaccines from another vet office or you will be charged and we will administer these vaccines. *

I accept

Pre-Anesthetic Bloodwork

Before anesthesia, we strongly recommend a pre-anesthetic blood profile. This profile will assess internal organ function before anesthesia. The cost is $82.46. *

Yes, I would like a pre-anesthetic blood profile
No, I do not want a pre-anesthetic blood profile

Intravenous Catheter and Fluids

An IV catheter and fluids are recommended to maintain your pet’s blood pressure and decrease the risks of organ damage from decreased blood pressure, prevent dehydration, and to aid in recovery, as well as to provide a life-line in the event of an emergency. The cost of the IV catheter with fluids is $152.97. *

Yes, I would like an IV catheter and fluids
No, I do not want a IV catheter and fluids

Antibiotics

I understand that my pet may be prescribed antibiotics after certain procedures if the doctor determines it is necessary. *

I accept

Pain & Anxiety Medications
***All spays and neuters will go home with several days of pain meds and this is included in the surgery price.***

For the comfort of your pet, the doctor will give your pet a pain injection prior to surgery. This is included in the cost of surgery. We strongly recommend that you also give pain medications orally for a few days after. This will help to ensure an easier recovery period. *

Yes, I would like pain medications for my pet
No, I do not want pain medications for my pet

Dogs that are energetic or hyperactive can sometimes benefit from having anti-anxiety medications (trazodone) for a few days after surgery. *

Yes, I would like trazodone to go home
No, I do not want trazodone to go home

Laser Therapy (Photobiomodulation) – Not Used on Growth Removals

Post-operative laser therapy will improve postoperative pain relief and provide faster incision healing. Light energy enters the cells to stimulate intracellular activity to provide these benefits. The cost is an additional $18.81 for use after surgery and $33.55 for use after dental cleanings. *

Yes, I would like post-operative laser therapy
No, I do not want post-operative laser therapy

Microchip

Would you like your pet to receive HomeAgain Microchip permanent ID while under anesthesia? In case they are lost or stolen they can be returned to you by the information in the chip.The cost is $59.14. This includes 1 year of registration. *

Accept
Decline

Elizabethan Collar

We recommend that most patients go home with an elizabethan (cone) collar to keep them from licking or chewing at their incision site. They need to wear it for 10-14 days, or until the incision is completely healed. If declined, owners will be financially responsible for additional care that result from your pet chewing or licking at the incision site. *

Accept
Decline

Growth & Tumor Removals

If your pet had a growth removed, you have the option to send the sample to a pathologist for microscopic evaluation and identification. The cost for this is approximately $290. It usually takes 5-7 business days to get the results. *

Yes, I would like to send a sample to a pathologist
No, I do not want to send a sample to a pathologist
My pet did not have a growth removed

Spay/Neuter Tattoo

We can give your pet a discreet, painless tattoo that is used to identify if a pet has been spayed or neutered. This is helpful if someone finds your pet and takes them to a veterinarian or an animal rescue. The cost of the tattoo is $5.40. *

Accept
Decline

Surgery Consent Form (Not Spay/Neuter)

Surgery Consent Form (Not Spay/Neuter)

Please complete the proper surgical consent form before your visit. We will get in touch with you if we have any questions.

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