consent - Wallace Vets

First Name *

Surname *

Street Address *

Postcode *

Contact Phone Number *

For the day of the procedure

Your Pet's Name *

Please select the species of your pet

Which practice are you booked into? *

I hereby give permission for the administration of a general anaesthetic and appropriate drugs to the above animal for the surgical procedure which they are booked in for, together with any other procedures which prove necessary.

I understand that all anaesthetic and surgical procedures pose a risk to the animal and that we cannot foresee any associated complications.

I understand that the Wallace Veterinary Centre shall try to contact me if any different treatment is recommended but if unable to do so shall do what they think is in the best interest of the above animal.

I understand that I need to fast my pet from midnight before the procedure?

Tick to confirm

I confirm that I have fed my pet as normal up until the time of their admission

Tick to confirm

Please also supply us with some of your pet's food for feeding after their procedure.

Does your pet have any health problems that we are unaware of? *

Yes

No

Please tell us about your pets health problems

Is your pet booked in to be neutered?

Yes

No

For Dogs over the age of 10 and Cats over the age of 13 we recommend pre-anaesthetic blood test to check liver and kidney function.

We also recommend fluids to maintain blood pressure and reduce affects of anaesthetic on the organs.

The costs of these are as follows:

Blood Test - £126

Fluids - £72

Would you like us to carry out a pre-anaesthetic blood test?

Yes

No

Would you like us to use Fluids?

Yes

No

Do you have any questions that you would like us to answer during admission?

Have you been given an estimated cost for this procedure?

Yes, I have

No, I have not

If you have not been given an estimated cost for this procedure, please contact us ahead of arrival to confirm.

Our main number is 01382 549600

Press 2 for Broughty Ferry

Press 3 for Carnoustie

Press 4 for Arbroath

__________________________________________

By signing below you are agreeing that you are the owner of the above named animal or are authorised by the owner and that you acknowledge that payment for this procedure is due at the time of discharge.

Signature *

Clear

Consent to Treatment or Surgery

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