Contact Information

Owner's Name *

First

Last

Pet's Name *

Procedure *

Best phone number to reach you *

Email

Like you, our greatest concern is the well being of your pet. Prior to anesthetizing your pet, our doctors will per form a complete physical examination. Please answer the following questions about your pet’s history and present health:

Is your pet currently taking any medications? List *

Yes
No

If yes, please list ALL current medications: *

Has your pet ever had any adverse reactions to any type of anesthesia or tranquilizer? *

Yes
No

Is your pet in heat or pregnant? *

Yes
No

****I understand if parasites (fleas, ear mites, intestinal parasites, etc.) are found on your pet while visiting our facility, we will treat the pet with the necessary treatment at the owner's expense for the protection of your pet and that of others in the hospital. *

I have read the foregoing, understand what it says, and agree.

****I understand that all pets over six months of age are required to be vaccinated for rabies according to state law. If your pet has not had the rabies vaccine prior to his/her visit, or if proper documentation cannot be provided, the pet must be vaccinated for rabies while here at the owner’s expense. *

I have read the foregoing, understand what it says, and agree.

****HW/Tick born screen - I understand that an up to date heartworm/lyme test for any dog over 7 months of age is required prior to going under anesthesia. There is a $70.00 charge for this service *

I have read the foregoing, understand what it says, and agree.

****I understand my pet needs to be withheld from food/water from midnight forward the night before surgery. *

I have read the foregoing, understand what it says, and agree.

Owner Authorization & Release:

I understand all anesthesia & surgery involves some potential risks and complications for my pet. I understand that I assume all responsibility for additional risks/complications resulting from refusal of these screening procedures, including financial responsibility should complications arise during the procedure(s) requested. You are to use all reasonable precautions against injury, escape, or death of my pet. I understand that anesthesia and surgery always involves some risk to my pet (such as unknown internal physical abnormalities, medication allergies, surgical complications, internal bleeding, shock, incision dehiscence, and post-surgical infections): and agree to hold you harmless, in the absence of negligence, in connection with these procedures. I acknowledge that no guarantee or assurance has been made to me as to the results that may be obtained. In the event complications arise and I cannot be immediately contacted at the phone number listed above, you are directed to make the decision you deem best for my pet. I agree to pay for services rendered. *

I have read the foregoing, understand what it says, and agree.

Signature of Responsible Party *

Date *

RECOMMENDED SERVICES FOR ANESTHETIC PROCEDURES

ECG (Electrocardiogram) - An ECG is a tool for diagnosing abnormal heart rhythm (arrythmia) and read by a boarded cardiologist (results back within minutes). We recommend this for all pets undergoing anesthesia, but especially pets over 7 years of age The cost of the ECG is $25. *

Accept
Decline

BLOOD TESTING

At Hamptonburgh Animal Hospital, we strive to practice quality medicine. We STRONGLY RECOMMEND that pets are properly screened. Many conditions, including disorders of the liver or kidneys or low grade infections can only be detected through blood testing possibly before your pet shows clinical signs of illness. Since most anesthetics are metabolized by the liver or kidneys, disease in one of these organs can increase the risk associated with anesthesia. If a problem is detected during the physical exam or on the blood work, a doctor will contact you to discuss any recommended course of action prior to surgery. Surgery will be postponed if it is deemed to be in the best interest of your pet. **Not needed if done withing past 1 month**

The cost for in-house pre surgical blood screen in animals less than 7 years is $66.00. The cost for in-house pre surgical blood screen in animals greater than 7 years is $132.00 *

Accept
Decline

IV CATHETERIZATION

When accepted, the IV Catheter will be placed prior to your pet being placed under anesthesia. In the unlikely event of a crisis while under our care, this allows for medication to be administered rapidly. **NOTE** Hair will be shaved at the catheter site(s).

The cost of the catheter is $45 *

Accept
Decline

MICROCHIP APPLICATION

1 in 3 pets go missing during its lifetime, and without proper ID, 90% never return home. A microchip gives the best protection with a permanent ID that can never be removed or become impossible to read. This is a small chip that is implanted under your pet’s skin on the back of the neck that is used for identifying your pet if he/she gets lost. We suggest that it is implanted while the pet is under anesthesia.

The cost of the microchip is $65.00 *

Accept
Decline

SPAY/NEUTERS

Clients who are having their female pet spayed should be aware that if she is pregnant, the puppies or kittens will all be aborted during the surgery. There is an additional charge for spaying a pregnant animal or an animal that is in heat, has had a previous heat, is overweight, or has retained testicle(s).

I am aware that if my pet has any of the above mentioned conditions there will be an additional charge.

DENTALS

For patients scheduled for dental cleanings: a dental cleaning for dogs and cats involves a FULL MOUTH health examination, cleaning, and extraction of teeth if necessary.

I am aware that if a tooth extraction is needed the doctor will perform the extraction (The cost of tooth extractions are $15-$35 per tooth depending upon complexity/location)

Laser Therapy (Photobiomodulation) - Not Used on Growth Removals

Post-operative laser therapy will improve postoperative pain relief and provide faster incision healing. Light energy enters the cells to stimulate intracellular activity to provide these benefits.

The cost of this treatment is an additional $20 *

Accept
Decline

BIOPSY

For patients scheduled for lumpectomy, we always recommend a biopsy to determine the make up of the removed tissue.

The cost of the biopsy is $210 *

I ACCEPT sending the growth/tissue that is removed to the laboratory for appropriate testing
I DECLINE sending the growth/tissue that is removed to the laboratory for appropriate testing.

PAIN MEDICATION: (FOR DOGS ONLY)

For certain procedures we strongly recommend that you also give pain medications orally for a few days after. This will help to ensure an easier recovery period.

The cost of routine pain medication is $15-$30 (depending on size)

Accept
Decline

Elizabethan Collar

We recommend that most patients go home with an elizabethan (cone) collar to keep them from licking or chewing at their incision site. They need to wear it for 10-14 days, or until the incision is completely healed. If declined, owners will be financially responsible for additional care that result from your pet chewing or licking at the incision site.

The cost of the collar is $19-$31(depending on size) *

Accept
Decline

Surgery Consent Form

Surgery Consent Form

Contact Information

Like you, our greatest concern is the well being of your pet. Prior to anesthetizing your pet, our doctors will per form a complete physical examination. Please answer the following questions about your pet’s history and present health:

Owner Authorization & Release:

RECOMMENDED SERVICES FOR ANESTHETIC PROCEDURES

BLOOD TESTING

IV CATHETERIZATION

MICROCHIP APPLICATION

SPAY/NEUTERS

DENTALS

Laser Therapy (Photobiomodulation) - Not Used on Growth Removals

BIOPSY

PAIN MEDICATION: (FOR DOGS ONLY)

Elizabethan Collar

Ready for a visit?

Request an appointment

Request an Appointment Online

Download Our PetDesk App

Questions?

We’re here to help.

Where to Find Us

How to Reach Us

Our Hospital Hours