Surgery Form

Save time ahead of your pet’s surgery by completing your required surgery form online before your visit.

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Eubank Veterinary Clinic Surgery Form

Please fill out this form as completely and accurately as possible so we can best prepare for your pet’s procedure.

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Client Information:

Name *

First

Last

Email *

Patient Information:

Birthday *

Anesthesia Consent Form for No Patient Allocated

Date and time of last meal: *

Date

Time

List of current medications *

Procedure(s) to be performed *

Veterinarian *

Stapleton *

As with any procedure requiring general and/or local anesthesia, there are certain risks that serious complications or even death may result. To minimize the risk of such occurrences, we recommend baseline bloodwork be performed in order to assure proper organ function, clotting ability, detect anemia or infection, baseline for future reference. The complete blood count (CBC) is a more sensitive indicator of disease than the physical exam. Additionally, white blood cells (WBCs) and platelets can change within hours due to acute infectious diseases. Abnormal glucose levels can increase anesthetic risk and differ markedly between fasted and non-fasted samples, breeds, age, and sick and healthy patients. Evaluating electrolytes, hematocrit and total protein in fasted patients is essential for monitoring during anesthesia, minimizing the risk of arrhythmias and hypotension, and facilitating patient recovery. *

Perform Preanesthetic Bloodwork
Perform Surgical Fluids
Decline Preanesthetic Bloodwork
Decline Surgical Fluids

As the owner of the above pet, No Patient, I certify that I am over the age of 18; and I authorize the staff of this hospital to perform the procedure(s) listed above, as well as those deemed necessary to treat life-threatening emergencies. As with all anesthetic, treatment, and/or surgical procedures, I understand there are risks inherent in these services. I acknowledge that staff members at this practice have explained the procedures to me, answered questions to my satisfaction and cannot be held responsible for any unforeseeable results. Further, I understand that I am financially responsible for all costs incurred during this surgery, treatment, and hospitalization.

While I accept that all procedures will be performed to the best of the abilities of the staff at this facility, I understand that veterinary medicine is not an exact science and that no guarantees have been made regarding the outcome of this/these procedures. I have read and understand the nature of the above procedures and accept the specific terms and conditions set forth herein.

Should unexpected life-saving emergency care be required I would like the hospital staff to attempt the following life saving measures (select one): *

Perform CPR
Do not attempt resuscitation

I acknowledge that I am responsible for payment in full for the above procedures and treatments at the time my pet is discharged.

Owner Signature *

Clear Signature

Date *

Surgery Form

Eubank Veterinary Clinic Surgery Form

Client Information:

Patient Information:

Anesthesia Consent Form for No Patient Allocated

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