Please fill out this form as completely and accurately as possible.

Client Name *

Patient Name *

Procedure to be Performed *

Phone number at which owner can be reached today or tomorrow *

Would you like a text notification when your pet is out of surgery?

Yes
No

I hereby authorize Van Crest Animal Hospital, and its designated associates to perform the above procedure(s). In addition, in the event that emergency treatment is required and I cannot be reached, I agree to any necessary diagnostic, treatment, or surgical procedures that are required. *

I understand and accept.

In order to maintain a healthy, clean, hospital environment, pets must be free of parasites (fleas, ticks) and be current on vaccinations. If necessary, pets will be updated on vaccinations and treated for any fleas or ticks at an additional charge. *

I understand and accept.

Additional Optional Services (Please mark if you approve any of these additional services)

Pre-Surgical Blood Screening: To identify potential health risks we recommend a more comprehensive blood testing, a CBC (complete blood count), indicates anemia, infection, or other cell related problems. Also included in the package is a blood chemistry to evaluate the liver and kidneys, as well as diabetes (this testing is required on all patients over 6 years of age). The cost is an additional $85.00. Includes: BUN (kidneys) ALKP(Liver) CBC(Complete Blood Count) Glucose(blood Sugar) Total Protein(Hydration) PVC (O2 saturation) ALT (Liver) Creatinine(Kidney) *

Approve
Decline

Microchip Identification Prepare for disaster. Very few pets find their way home without permanent identification. We can implant a MICROCHIP while the pet is sedated for $53.00. *

Approve
Decline

Other optional procedures that may be done at less cost since the pet is already sedated include(check if wanted):

Nail Trim $14.50
Pedi-Paw Additional $9.50
Ear cleaning $17.00
Express Anal Glands $15.00

**EVEN WITH ALL PRECAUTIONS, ANY TIME AN ANESTHETIC AGENT IS GIVEN OR SURGERY IS PERFORMED, THERE IS ALWAYS THE POSSIBILITY OF LOSS OF LIFE.** *

I understand and accept.

Signature *

Clear Signature

I have read and understand this consent form, and I agree to pay for services rendered at the time my pet is discharged or when service is otherwise completed.

Date *

Surgery & Anesthesia Consent Form

Surgery & Anesthesia Consent Form

Additional Optional Services (Please mark if you approve any of these additional services)

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vancrest@vancrestonline.com

803-794-6550

1817 Augusta Rd, West Columbia, SC 29169

Monday, Wednesday, and Friday 7:30-1 PM and 2 pm to 6 pm

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