Surgical Consent Form

Please only use this form if directed to by a member of Lone Mountain Animal Hospital’s staff as this form is used to authorize us to perform surgery on your pet.

Pet Owner Contact Information

May we text you? (optional)
YesNo

Pet History

Are vaccinations current? (required)
YesNo

Does your pet have a history of seizures? (required)
YesNo

Has your pet had any illnesses in the past 30 days? (required)
YesNo

Is your pet allergic to any medications that you are aware of? (required)
YesNo

Did your pet eat this morning? (required)
YesNo

I am the owner, or agent, of the above animal and have the authority to execute this consent. I hereby authorize the following procedures:

Pet Procedure (required)

Laser Surgery
Laser surgery can be used on most surgical procedures. Benefits include decreased pain, swelling, and bleeding. Additional fees apply for laser use ($80).
Yes - I want this for my pet.No - I do not want this for my pet.

Pre-Op Blood Work
For the protection of our patients, we recommend preoperative blood work to screen for health conditions that may represent an additional anesthetic risk. Multi-Panel for pets less than 5-years-old: $105; full-panel for pets 5-years-old or older: $139.
Yes - I want this for my pet.No - I do not want this for my pet.

HomeAgain Microchip
This includes the Pet Recovery Fee.
Yes - I want this for my pet.No - I do not want this for my pet.

Certain procedures can cause some degree of pain and/or discomfort. Pain medication will be administered to patients whenever appropriate. Reasonable precautions will be used against injury, escape, or death of this pet. All anesthetics do present a risk to the health of my pet. I accept these risks as part of the procedure(s). I realize that the results cannot be guaranteed, and that payment is due in full at the time of discharge. By signing below, I indicate that I understand and agree to the above information.

Pet Owner's Signature (required)

Today's Date (required)

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