Owner/Agent *

Email *

Date

Best Phone number

My pet, is here for sedation/anesthesia/surgery. I understand that adequate kidney and liver function is essential to the breakdown and removal of common anesthetic agents from the body. A pre-anesthetic panel consisting of the following tests are recommended by the Veterinarian for all patients to ensure the anesthetic agents are moved from my pet's system: Kidney tests: along with physical examination findings and a complete urinalysis, will help assess your dog’s hydration status and kidney function. Results may reveal that he has kidney disease and how bad it is. Liver results: can reveal problems in the liver, gallbladder and/or bile ducts. Potential causes include inflammation, toxin exposure and certain endocrine disorders. Additional tests may be indicated to determine the cause of the liver test abnormalities. Electrolyte results: can reveal evidence for Addison’s disease, acid-base imbalances and certain other medical problems. A complete blood count (CBC): can reveal inflammation, inability to fight infection or leukemia, among other things. It may also indicate low platelets, which can result in bleeding tendencies or anemia. *

I have read and understand

See your veterinarian for a complete list of preanesthetic tests. The combined cost for this pre-anesthetic panel is included in the price of Spay/Neuter package.

Canine and Feline Spay

Is your pet a female or male?

Female
Male

Female Patients:

IF you have a female pet and she may be in heat or may have been bred, there are additional risks as well as additional charges that will apply. To the best of my knowledge my animal is: *

In heat/or pregnant
Not in heat or possibly pregnant

Male Patients:

If you have a male pet that is over the age of 5 months, and both testicles have not descended, there are additional RISKS as well as additional charges that will apply. To the best of my knowledge my animal: *

Has only one descended testicle
Has been examined and confirmed to have both testicles descended.

E-Collar

An Elizabethan collar (also known as an E-collar or the cone of shame) are plastic or fabric hoods or cones placed around the head to prevent an animal from licking at a surgery site, wound, or dressing.

Plastic: Clear/see-through, custom sizing for neck and length Cost: $23.00-$32.50
No- I have an e-collar already and I will bring it to the discharge appointment
Per the Doctor, this procedure doesn’t require an e-collar

Package Cost Breakdown

Feline Spay:

Package Price: $165.50

Discount: $100.00

Full Package Price: $265.00

Canine Spay 1-15lbs:

Package Price: $175.00

Discount: $100.00

Full Package Price: $275.00

Canine Spay 16-30lbs:

Package Price: $190.00

Discount: $100.00

Full Package Price: $290.00

Canine Spay 31-50lbs:

Package Price: $210.00

Discount: $100.00

Full Package Price: $310.00

Canine Spay 51-70lbs:

Package Price: $220.00

Discount: $100.00

Full Package Price: $320.00

Canine Spay 71-over lbs:

Package Price: $250.00

Discount: $100.00

Full Package Price: $350.00

Feline Neuter:

Package Price: $145.00

Discount: $100.00

Full Package Price: $245.00

Canine Neuter 1-15lbs:

Package Price: $165.00

Discount: $100.00

Full Package Price: $265.00

Canine Neuter 16-30lbs:

Package Price: $170.00

Discount: $100.00

Full Package Price: $270.00

Canine Neuter 31-50lbs:

Package Price: $190.00

Discount: $100.00

Full Package Price: $290.00

Canine Neuter 51-70lbs:

Package Price: $210.00

Discount: $100.00

Full Package Price: $310.00

Canine Neuter 71-over lbs:

Package Price: $250.00

Discount: $100.00

Full Package Price: $350.00

Multi-Parameter Surgical Monitor Offered

During your pet's surgical procedure, we always use equipment which monitors their pulse rate, respiratory rate and blood oxygen concentrations for safety at no charge. We now offer a multi-parameter surgical monitor for even MORE safety during the surgical procedure. The M-P monitor now allows us to monitor the heart itself with electrocardiogram (ECG), heart arrhythmia warnings, blood pressure monitoring, heart rate, respiratory rate, oxygen concentration and core temperature monitoring. This additional safety monitoring is (Included). *

I have read and understand

Pain Management

Pain medication is optional, but HIGHLY IMPORTANT. It will be administered DURING surgery to aide in keeping your pet comfortable during the recovery process and their first night of recovery. Additional medication is also included in your surgery package. *

I have read and understand

Therapeutic

We now offer medical laser therapy for your pet immediately after surgery to help reduce any swelling and local pain around the incision site. Included in Spay/neuter package. *

I have read and understand

****NOT AVAILABLE FOR MASS REMOVAL SURGERIES OR EYE SURGERIES*****

Propofol Pre-Anesthetic Agent

While our general anesthesia is very safe, propofol can be added for additional safety especially HIGH RISK and Cardiac patients. It is Required for patients 7 years and older, certain breeds of both Feline (cat) and Canine (dog) patients. *

I have read and understand

Microchip *

I authorize for my pet to be microchipped
No, I would like to decline microchipping at this time
My pet is already Microchipped.

Life saving measures (CPR)

In the event of Cardiac Arrest during hospitalization (hear or breathing stops): *

I request emergency and lifesaving procedures (including Cardiopulmonary resuscitation) be performed immediately on my pet. I understand I will not be contacted prior to these actions and give permission for the doctors and staff at Town and Country Veterinary hospital to take reasonable measures in treating my pet. I accept all additional charges that are incurred as a result of action. I understand Initiating CPR does not guarantee survival.
DO NOT resuscitate (DNR). I understand Town and Country Veterinary Hospital will do everything possible to keep my pet stable during hospitalization and/or the procedure. If my pet has unstable vital signs, our staff will perform necessary steps to stabilize him/her. However, if my pet suffers cardiopulmonary arrest (hear stops, breathing stops), the staff will NOT attempt CPR. I understand this will lead to death.

Financial Options

I authorize Town and Country Veterinary Hospital to perform the procedures(s) outlined in the associate treatment plan on my pet. I understand the itemized treatment plan is a good-faith representation of what will be performed during this procedure. If Town and Country Veterinary Hospital encounters any NON-EMERGENCY, unexpected complications, or medical conditions that require the treatment plan to be altered, every effort will be made to contact me as these issues arise. In the case the hospital staff is unable to contact me, Town and Country Veterinary Hospital will follow my instructions as outlined below. *

If unexpected complications or medical problems arise during my pet’s hospitalization and I cannot be reached at my contact phone number:
DO NOT perform any treatment or diagnostic testing on my pet that was not outlined in the treatment plan presented to me today. I understand that in some situations, this decision may negatively impact my pet’s health, and I take responsibility for delaying care. In making this decision, the doctors and staff at Town and Country Veterinary hospital will not be held liable or responsible for the results of my decision. I understand that should I choose to pursue these recommendations at a later time, follow-up charges will apply in addition to today. Recommendations for unexpected additional services may change as my pet’s clinical status changes.
Perform additional treatments/services deemed medically necessary by the attending doctor as detailed below. I understand these services were not listed on the treatment plan presented to me and thus additional charges are my responsibility (due at discharge). Town and Country Veterinary Hospital staff will make every attempt to contact me at the numbers I provided before proceeding with the additional services. Treatments/diagnostics that are purely elective, or that will not benefit my pet's immediate health will not be performed without my permission.

If unexpected complications or medical problems arise during my pet’s hospitalization and I cannot be reached at my contact phone number: *

I am over 18 and understand that I accept that all procedures will be performed to the best of the abilities of the staff at the hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow-up radiographs, re-check physical exam and additional surgery due to post-op complication. These are more likely to occur when there is a failure to comply with the aftercare instructions. I have been provided an estimated cost for the procedure(s) listed above. I assume financial responsibility for the recommended services and will provide payment in full at the time my pet is discharged from Town and Country Veterinary Hospital. I have read and fully understand the terms and conditions set forth above. *

I have read and agree.

Owner Name *

Owner Signature *

Clear Signature

Todays Date *

Pre-surgical Questionnaire

Best phone number to reach you today: *

How is your pet’s energy level? Describe their normal activity or routine. How do they tolerate exercise? *

Normal
Moderate
Sudden changed: (please explain):

If sudden changed, please explain *

Has your pet had any of the following occur in the past week: *

Does your pet have a history of any of the following: *

If other, please explain *

Is your pet allergic to any medications, including anesthesia: *

No
Yes (please explain):

If yes, please explain *

Have you given your pets any medications or supplements in the past week? *

Yes (please specify):
No

If yes, please explain (copy) *

What time did your pet last eat and/or drink? *

Do you have any questions or concerns you would like to speak to a staff member about?

Please make sure to check out the Surgery Handout by clicking here.

New Hours

Online Form

Spay and Neuter Surgery Authorization and Release Form Town and Country Veterinary Hospital

Spay and Neuter Surgery Authorization and Release

Canine and Feline Spay

E-Collar

Package Cost Breakdown

Multi-Parameter Surgical Monitor Offered

Pain Management

Therapeutic

Propofol Pre-Anesthetic Agent

Life saving measures (CPR)

Financial Options

Pre-surgical Questionnaire

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