Canine Surgery Consent Form in Andover, MA

Client Name*
Client ID #
Patient Name*
Procedure(s)*
Date
MM slash DD slash YYYY
Emergency Contact #
General Anesthesia:
Pre-Surgical Blood Screening:*
I understand my pet will have blood drawn for routine screening based on his/her age. This screens for anemia, dehydration, blood sugar, and internal organ function.

I understand a negative Heartworm Test is required within one year of my pet's procedure, and my pet will be tested if he/she is not up to date at the additional cost of $83.
- I understand
Bloodwork already completed on this date
Fluid Administration*
Subcutaneous fluids are given underneath the skin to prevent dehydration and speed anesthetic recovery. I understand my pet will receive Sub-Q fluids during his/her procedure.

IV fluids are required for pets 7 years of age or older, and recommended for sick pets, or pets who will be under general anesthesia for one hour or more. This is the best way to maitain blood pressure, hydration, and to provide rapid venous access in the event of an emergency. I understand my pet will receive IV fluids during his/her procedure.
- I understand
Pain Medication*
I understand that pain medication is used with every procedure and aids in a more comfortable and faster recovery. I understand that for most surgical procedures I will be given additional pain medication to give my pet at home
- I understand
Please microchip my pet during his/her procedure at the additional cost of $66. This includes the microchip and the first year of registration.*
- Yes
- No
Please trim my pet's nails during his/her procedure at the additional cost of $21*
- Yes
- No
Flea and Tick preventative is required for all animals admitted to the hospital within 30 days all year round.
Has a flea and tick preventative been given?*
- Yes
- No, Please give K9 Advantix II at my expense
Please indicate what preventative has already been given:*
Emergency Treatment*
- I hereby authorize treatment up to and including chest compressions, medications, and artificial respiration in the case of an unforeseen emergency. I understand that these interventions can be costly and outcome is not guaranteed. If the hospital staff is unable to reach me, and the doctors' medical judgment determines that there is no hope for success, I understand the staff will discontinue resuscitation
- Do Not Resuscitate my pet (DNR). I wish to be notified prior to treatment of an unforeseen emergency. I understand that the delay in treatment could result in serious complications, including death.
Please initial: I understand that my pet is not supervised overnight*
Dental Procedures
Estimated Levels 1 and 2
I understand extractions are rare, but may be necessary. Two x-rays and extractions along with additional pain medicine are at an additional cost of $230 - $400.
- I understand
Full mouth x-rays are recommended as standard of care and are the only way to fully evaluate the health of your pet's teeth*
- I approve baseline full mouth x-rays for my pet during his/her dentistry. Additional cost is $186
- I decline baseline
Estimated Levels 3 and 4
I understand extractions are rare, but may be necessary. Two x-rays and extractions along with additional pain medicine are at an additional cost of $150-$275.
- I understand
Vaccinations
All animals must be up to date with required vaccines to board in our facility. Any needed vaccines administered will require an exam for the additional cost of $95.

Any exam, vaccinations and/or testing required for boarding will be done and charged to your account without prior documentation.
Please mark the needed vaccines and procedures. (Ask a staff member if any questions)
- Wellness Exam $95
- Canine Dist (DHLPP or DHPP) $38 (Exam req)
- Leptospirosis $38 (Exam required)
- Rabies $32 (Exam required)
- Bordatella/Parainfluenza $45
- Canine Influenza $50
- Lyme $57
- Fecal Sample $53
- Heartworm Test (4DX) $83
- Heartworm Test and Wellness Screen (ages 2-6) $181
- Senior Wellness Screen (ages 7 and up) $207
We will be vaccinating your pet while he/she is here as indicated above. We want to inform you there is a possibility your pet may experience lethargy and a mild fever for 24-48 hours. This is a typical response. Adverse reactions include severe vomiting or diarrhea, difficulty breathing, hives and/or swollen face. Reactions usually occur within 30-60 minutes from vaccination but can occur up to 24 hours later. If your pet has a reaction, we will contact you immediately*
- I have read the above paragraph
I hereby give my consent and authorize the use of general anesthesia for my pet. Andover Animal Hospital strives to decrease anesthetic risk by doing pre-operative examinations and labwork. In some cases the doctor may recommend intravenous fluids and/or further diagnostic tests.

There is always risk with anesthesia. Risk of anesthesia can include cardiac or respiratory arrest, rarely causing death. Other possible anesthetic complications can include allergic reactions, vomiting leading to pneumonia, eye irritation or damage, irritation or injury to the throat, blindness, deafness, cardiac arrhythmias, slow anesthetic recovery, seizures, vomiting, diarrhea, lethargy, coughing, excitement, low or elevated body temperature, and organ damage.

Andover Animal Hospital cannot be held accountable for unforeseen anesthetic complications or cost associated with unforeseen anesthetic complications. I have read and understand the possible complications associated with anesthesia for my pet.

I understand that my pet is not supervised overnight.
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Canine Surgery Consent Form

General Anesthesia:

Dental Procedures

Vaccinations

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