Surgery Permission Form

Owner's Name:

Street:

City:

Phone:

Pet's Name:

Breed:

Sex: --- Male Female

Age:

Color:

Please describe the surgery:

I hereby certify that I am the owner (or duly authorized agent for the owner) of the animal described above, that I do hereby give Ricky Van Matre, DVM, his/her agents, servants and/or representatives full and complete authority to perform the surgical procedure as described and to perform any other procedure that, at his discretion, may be useful to promote the health of the above described pet, and I do hereby forever release Ricky Van Matre, DVM, his agents, servants, and representatives from any and all liability arising from said surgery on said animal.

To minimize the risk of anesthesia and surgery, pre-anesthetic blood work and ECG is strongly recommended prior to all anesthetic procedures.

• I accept the recommended pre-anesthetic blood work
• I decline the recommended pre-anesthetic blood work

In animals less than 5 years old, with no existing medical problems, the minimum recommended blood work is a 10-Panel Blood Chemistry and Complete Blood Count. The cost of this test is $79.50.

In animals 5 years or older, or those with medical problems, the required workup is a 17-Panel Blood Chemistry Profile with a Complete Blood Count. The cost of this test is $134.50.

A pre-anesthetic ECG to test heart function and heart rhythm is strongly recommended prior to surgery. The cost of this test is $59.50.

• I accept the recommended pre-anesthetic ECG
• I decline the recommended pre-anesthetic ECG

While your pet is under anesthesia, it is an opportune time to do other procedures. Please select from the following procedures for your pet. Nail trims are half-priced while under anesthesia.

 

• Dental Cleaning ($250)
• Hip X-Rays (single view-large breed only) ($90)
• Nail Trim ($10)
• Ear Cleaning ($20)
• Growth Removals (Varies) Locations:
• Microchip Implantation ($65)
• Ear Plucking ($25)
• Other

THE PRESURGICAL TEST COSTS ARE IN ADDITION TO THE COST OF THE SURGICAL PROCEDURE.