Surgical Consent Form

Click HERE to print a copy of the form
or fill out the online form below

Pet’s Name/Owner’s Name
Phone
*THE FOLLOWING ARE ADDITIONAL CHARGES *
ECG: $60 We highly recommend an ECG to make sure that your pet’s heart is working properly prior to the procedure.
- I Accept
- Doctor’s Discretion
- I Decline
BLOOD WORK: $110 We highly recommend that patients receive pre-operative blood work to access overall health as to minimize the risks of surgery and anesthesia.
- I Accept
- Doctor’s Discretion
- I Decline
ANTIBIOTICS: $60-$150 We highly recommend the use of post-operative antibiotics to minimize pain and inflammation that could be associated with surgery
- I Accept
- Doctor’s Discretion
- I Decline
PAIN MEDICATION: $30-$100 We highly recommend the use of post-operative medication
- I Accept
- Doctor’s Discretion
- I Decline
LASER THERAPY: $40 Therapeutic laser used during surgery or dental procedure to decrease pain and lower inflammation as well as speed healing.
- I Accept
- Doctor’s Discretion
- I Decline
LASER THERAPY: $40 Therapeutic laser used during surgery or dental procedure to decrease pain and lower inflammation as well as speed healing.
- I Accept
- Doctor’s Discretion
- I Decline
There will be an additional charge for animals that are overweight, in heat, or have retained testicles. I am aware of these possible charges.
- I Accept
- I Decline
Ultrasound Wellness Screen $100 Ultrasound (also called sonography) is a technique that uses sound waves to image structures in the body. During the ultrasound, high-frequency sound waves are transmitted to the area of interest in the body and the returning echoes are recorded.
- I Accept
- Doctor’s Discretion
- I Decline
Release: I hereby consent and authorize Clint Moore Animal Hospital to perform treatment or operate on my pet. The Clint Moore Animal Hospital staff are to use all reasonable precautions against injury, escape or destruction of animal(s) but will not be held liable or responsible in any manner whatsoever for an incidents or circumstances that occur as in regard to care of the animal. Treatment and safe keeping of the animal(s) in connection there with, as it is thoroughly understood that I, as the owner, assume all risks. If animal(s) is/are not picked up on date specified, written notice will be mailed to the owner’s address on file to remove the animal(s). If the animal(s) is/are not picked up within five days after such written notice, the animal(s) will be considered abandoned and become property of Clint Moore Animal Hospital, and it is understood that in such circumstance this does not relieve you from paying all costs of your service and the use of the hospital, including cost of keeping the animal(s). I have read all the above and agree:
Signature*
Date