Patient Surgery and Dental Consent Form

Please enter Your Name:
Pet’s Name:
Your Email:

Contact number:
Alternate number:
Procedure(s) to be performed:
Was your pet fasted overnight and this morning? YesNo
What medications or supplements does your pet receive?
When was the last time your pet received these medications?
Have you noticed any CoughingSneezingVomitingDiarrhea
If yes, please explain and note when you first observed symptoms:
Current Heartworm prevention: Last dose given?
Current Flea/Tick prevention: Last dose given?
Does your pet receive any dental care at home (teeth brushing, dental treats, water additives, etc)? How
often?
Is your pet sensitive or allergic to any medications/food/vaccines? YesNo
If yes, please explain:
Has your pet shown any previous fear/anxiety/stress at the veterinarian? YesNo
If yes, please explain:

Please indicate whether you would like us to:

Call you first if additional services are needed with a treatment plan amountTreat as necessary, up to $:

Dental patients

Call you before proceeding with needed tooth extractions or Periodontal FillerProceed as necessary, up to $:
**Tooth extractions are charged at $6.50/minute. Periodontal Filler $75/vial

Additional Services I would like performed:

Microchip implantation and Registration $46Nail Trim $18.50Ear cleaning $15Anal gland expression $25

Medical and surgical treatments, including anesthesia, are not without risks. We will do everything we can to ensure your pet receives the safest and most up-to-date medical and surgical care. However, complications do occasionally arise during or after a medical or surgical procedure.

Complications include but are not limited to:

In the event of a complication, the veterinarian will proceed with treatments based on your pets chosen CPR/DNR status below. Any costs associated with emergency treatments are incurred at the owner’s expense.

Emergency Services – please choose ONE of the following options:

In the event that my pet undergoes respiratory arrest (stops breathing) or cardiac arrest (heart stops beating) while here at Fullwood Animal Hospital, I authorize the following CPR code:
CPR: medical intervention involving intubation, IV catheter placement, chest compressions, oxygen therapy and medications such as epinephrine, atropine, etc.DNR: No resuscitation – heroic efforts will not be used to save my pet.

Please read and initial EACH option below (mandatory):

Social Media Release (optional):

Charges for all services must be paid in full at the time of discharge.

By checking below, authorizes the veterinarian to perform treatment plan procedures and any emergency treatments that may become necessary. Is also releases Fullwood Animal Hospital of any liability associated with the treatment of your pet.