This is our surgery form, to be filled out in the event of routine Reproductive Surgeries (Spay and Neuter), Dental Cleanings, Emergency Surgeries, Etc.

If you would like, we also have printable forms available for you to print out and bring in with you.

Unless other arrangements have been made, we have standard times of discharge for our patients. We like to assure that every patient spends the proper amount of time in the clinic where they can be monitored closely until the anesthetic is out of their system, as well as not injure themselves doing too much too soon. In other words, they need some quiet pampering. We also have to schedule pick-up times allowing for the doctor's time.

Dental (teeth) Cleaning Patients will go home the same day, after 4:30pm.

Patients who have been Spayed (females) will go home the day after surgery after 10am.

Patients who have been Neutered (males) will go home the same day, after 4:30pm.

Form - Elective Procedure Authorization

Name (required)
First Name (required)
Last Name (required)
Your Pet's Name: (required)

Phone Number (where you will be available during surgery) (required)
Phone TypePhone Number (required)
May we use the number above to text you information about your pet?
yes
no

Alternate Phone Number
Phone TypePhone Number
May we use the number above to text you information about your pet?
yes
no

E-Mail Address :
Please take time to review this sheet, and sign the authorization.
Authorization
I am the owner or agent of the above described animal and have the authority to execute this consent. I hereby consent and authorize the performance of the following procedure(s) or operations(s):
Please enter the procedure(s) or operation(s) to be performed: (required)

Explanation of Anesthesia:
Explanation of Pre-Anesthetic Blood work:
Your pet is with HCH for a procedure that will require a sedative and/or anesthesia. If this is your first visit with HCH, there will be a charge for a full physical examination of your pet prior to (at least one day ahead of time) surgery to insure that there are no existing health problems that could possibly lead to complications during the procedure you have scheduled. We require a pre-anesthetic blood profile for the safety of your pet, this checks for adequate number of red and white blood cells, platelets and to check proper function of the kidneys and liver which may not be evident during physical exam
My pet has had the pre-anesthetic blood testing performed within the past 30 days.
Pain Control:
Pain medication will be given to your pet as needed. Animals undergoing surgical procedures will generally receive pain medication each day while in the hospital and will usually be sent home with additional medication.
Sevoflourane Anesthesia:
Sevoflo may be recommended for your pet at the discretion of your veterinarian. Sometimes this anesthetic is superior to other protocols, especially for older, debilitated animals. If this has been chosen by your veterinarian, there will be an additional charge to the anesthetic cost.
I understand that if my pet is in heat during a Spay procedure, I will be charged an additional $30 (required)

Explanation of Dental/extractions:
Dental Information:
Many animals have diseased teeth from periodontal disease or from enamel erosions. These teeth are painful and should be extracted. Often we will not discover the damaged teeth until the dental exam is performed while your pet is under anesthesia. Sometimes radiographs (X-rays) will be necessary to determine if a tooth should be extracted. Young animals often have retained baby teeth that must be removed to allow the permanent dentition to erupt properly. While your pet is here for spaying/neutering, we should remove any baby teeth that are present.
Please choose one option:
I authorize the extraction of damaged teeth and performance of any X-Rays that are deemed necessary.
I wish to be called with an estimate before any extractions are performed.

I will be readily available at the phone number above in case of any additional findings.
Please read:
I understand that if I cannot be reached, the extractions will not be performed and will necessitate a second procedure with anesthesia at a different time.
Are there any other services you would like performed today while your pet is under anesthesia?
I understand by checking these boxes I am initialing additional procedures at additional cost. (required)

I authorize the extraction of any deciduous (baby) teeth as necessary
Please complete dental cleaning/treatment if indicated.
Please complete a urinalysis. (Recommended if >6 yr)
Please radiograph my pet's chest to detect possible heart/lung disease. (Recommended if>6yr)
Please remove the indicated growths or tumors on my pet. (Indicate location below)
Please indicate location of tumor/growth(s):

Please scan my pet, if no microchip is found, please permanently identify with a microchip.
Please trim my pet's nails if indicated. (complimentary)
Please clean my pet's ears if indicated.
Please express my pet's anal glands.
Please brush or clip out mats if indicated.
In the event that my companion animal arrests while hospitalized at Hebron Cat Hospital
I authorize the following CPR code: (required)
(by making your selection, you are initialing your choice)
Normal CPR: involving chest compressions, oxygen therapy and medications such as epinephrine, atropine, etc
DNR: No resuscitation

Please read carefully:
Final Authorization:
I am the owner/agent for described animal and I authorize and request the services listed on this form and discussed above. I have indicated any additional services I would like performed with my initials and checked boxes. I understand that during the performance of the foregoing procedure(s) or operation(s), unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure(s) or different procedure(s) than those set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) as are necessary and desirable in the exercise of the veterinarian's professional judgment. I also authorize the use of appropriate anesthetics, other medications and I understand that hospital support personnel will be employed as deemed necessary by the veterinarian. I have been advised as to the natures of the procedure(s) or operation(s) and the risks involved. I realize that results cannot be guaranteed.
I understand that I will be charged for flea medication administered if evidence of fleas is found.
To the best of my knowledge, my pet has not had any food since 10pm the night before surgery. (required)

I have read and understand this authorization and consent. (required)


The verification code below ensures the form is not submitted by a computer
Verification Code :
Enter the code you see in the graphic below in this box.
Your post will not be allowed if you do not type this in correctly.