Surgical Consent

please complete the form below

    CLIENT INFORMATION

    My pet is having the following procedure today

    PET INFORMATION

    Name

    Breed

    Age

    Species
    CanineFelineOther

    Is your pet

    Having any vomiting?
    NoYes

    Having any diarrhea?
    NoYes

    Having any coughing?
    NoYes

    Having any sneezing?
    NoYes

    Have you noted that your pet is experiencing weight loss?
    NoYes

    Is your pet experiencing any pain?
    NoYes

    Pet's appetite?

    Pet's drinking?

    Pet's urination?

    MEDICATION/SUPPLEMENTS

    Is your pet on any medications?
    If yes, please list name, dose, and how often administered
    NoYes

    Does your pet receive any supplements?
    If yes, please list drug name, dose, and how often it is administered
    NoYes

    Does your pet have any known medication allergies?
    NoYes

    Does your pet have any previous medical conditions?

    If your pet needs medications to go home after their procedure, do you prefer

    CONSENT