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Pre-Surgical Letter & Surgery Consent Form
Pre-Anesthesia Checklist
• Please remove all food after midnight the night before your pet's procedure (water is fine).
• If you already have an Elizabethan collar, please bring it in when you drop off your pet for surgery (unless the only procedure is a dental).
• Please have your pet here between 7:30 am-8 am. Please allow 15-20 minutes for check-in to answer any questions you or our staff may have about the procedure.
• Pick up your pet anytime between 3:30 pm and 4 pm (4:30 pm at the latest) on the same day as the procedure.
Please allow 10-15 minutes for a technician/doctor to go over your pet's home-care instructions and any questions you may have. Occasionally we may need to contact you while your pet is with us before, during, or after anesthesia.
Please plan to have a phone number which we can contact you
or an authorized agent at any time on the day of the procedure. If you have any questions regarding your pet's upcoming procedure, please call us at
(850) 939-1373
. We look forward to seeing you and your pet! Sincerely, The Doctors and Staff of Navarre Animal Hospital
This letter is to confirm that your pet is scheduled for a surgical procedure on:
*
Date Format: MM slash DD slash YYYY
*
I have read and understand the pre-anesthesia checklist above
Today's Date:
*
Date Format: MM slash DD slash YYYY
Name
*
First
Last
Best Phone/Contact Number:
*
Email Address:
*
Secondary Contact Information (Phone, email):
Pet's Name:
*
Reason for Admission:
*
Date of procedure:
*
Date Format: MM slash DD slash YYYY
*
I certify that I am the owner, or authorized agent for the owner of the pet named above. I understand my pet will be undergoing a procedure requiring general anesthesia today, and do hereby give my consent and authorize Navarre Animal Hospital and it's staff to hospitalize this pet and perform the above described procedure(s) necessary for it's health, safety and well-being.
I have been advised as to the nature of the procedure(s) and the potential risks, including death, and understand the reason why such medical and/or surgical treatment is considered necessary, as well as its advantages and possible complications, if any. I also understand that no guarantee of successful treatment or outcome can be made.
Pre-Anesthetic Blood Work
We recommend blood work prior to anesthesia in order to screen for major organ dysfunction and potential greater anesthetic risk. This is required if your pet is 7 years or older.
*
I DO want pre-anesthetic blood work for my pet
I DECLINE pre-anesthetic blood work for my pet
My pet is 7 years or older and I understand pre-anesthetic blood work is REQUIRED
Elizabethan Collar or Medical Pet Shirt
If you have an e-collar or medical pet shirt at home you can bring it with you upon your pet's admission. We require your pet to wear an e-collar and/or medical pet shirt. for 7-14 days to protect their incision from trauma caused by licking or chewing.
*
I DO want an elizabethan collar
I DO want a medical pet shirt
I will bring my own collar/pet shirt with me that morning
Microchipping
This is a permanent form of identification implanted under your pet's skin and can be done during your pet's procedure.
*
I DO want to microchip my pet
I DECLINE to microchip my pet
My pet is already microchipped
*
I understand that it is impossible to accurately estimate the total charges involved as the total extent of the injuries or illness may not be immediately present. The results of blood tests, urinalysis, radiographs, etc. may be needed before the doctor can approximate a total expense. I also understand it is impossible to accurately estimate the time and individual animal needs to respond to a treatment plan and this factor may affect the total cost.
I would like Navarre Animal Hospital to contact me if additional treatment is needed that exceeds the estimated range. I understand an updated treatment plan and estimate will be provided with my permission obtained to proceed should I be available. I understand and plan to have a phone number which Navarre Animal Hospital can contact me or an authorized agent for my pet any time on the day of the procedure.
*
Yes
No
Signature (Please type your first & last name)
*
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Home
About Us
Our Team
Reviews
Wellness Plans
Services
Pet Wellness
Wellness Plans
Vaccinations
Dentistry
Dermatology
End of Life Care
Microchipping
Nutrition
Pain Management
Parasite Prevention
Radiology
Surgery
Resources
How-To Videos
News
Online Pharmacy
Pet Food Recalls
Pet Health Checker
Pet Health Library
Pet Insurance
Forms
Drop-Off Hospital Admission Form
New Client Information Form
Surgery Consent Form
Contact Us
Emergency
Schedule Appointment
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