Surgery Permission Form

Surgery Consent Form

This a request form to be filled out by clients whose animals are scheduled for surgery at the Baeyens-Hauk Veterinary Hospital
  • Animal Name:________________________________________ Breed:__________________________________________________. Age:____________________________________________________. Sex:_____________________________________________________.
  • Like you, our greatest concern in the well being of your pet. Before any medications are given to your pet, a pre-anesthetic examination is performed. BHVG recommends that in addition to this exam, a blood profile should be evaluated to maximize patient safety and alert the doctor to the presence of any preexisting conditions that may complicate the procedure, Pre-anesthetic blood work will be performed on all pets over the age of 7 years.
  • Chemistry Profile: Evaluates vital organ function and electrolytes to ensure that the anesthesia is as safe as possible. CBC (Complete blood count): Evaluates the numbers and characteristics on red blood cells, white blood cells and platelets.
  • ________Yes: Please complete the recommended bloodwork. I assume full responsibility for all services rendered. _________No: I have elected to decline the recommended bloodwork at this time. I assume full financial responsibility for all services rendered.
  • Authorization and Risk Assessment I hereby certify that I am the owner of the above named animal or I am responsible for the above named animal and have the authority to execute this consent. I authorize sedation/anesthesia/surgery for my pet. The nature and risks of this procedure have been explained to me. I understand that some risks always exist with anesthesia/sedation, and I am encouraged to discuss any concerns I have about these risks with my veterinary hospital before the procedure(s) are initiated. Initials____________
  • Baeyens-Hauk Veterinary Group 8620 Hwy 107 Sherwood AR 501-837-7106