Skip to content
(972) 775-2901
Online Pharmacy
Careers
hours
location
RX
Careers
Home
Our Practice
Our Team
Take a Tour
Services
Paws & Read
Contact Us
Pet Corner
Forms
Resources
Payment Options
Today:
8:00 am - 6:00 pm
Open Hours
(972) 775-2901
Phone Number
840 E Main St
Midlothian, TX, 76065
Request an Appointment
processingbanners
today:2023-03-21
Surgical Consent Form
Client Name
Patient Name
What is the best way to reach you today?
Surgical procedure to be preformed:
Your pet will be undergoing general anesthesia plus a surgical procedure today. In order to recognize any underlying abnormalities your pet may have, we recommend having a pre-surgical blood profile run on your animal. This consists of a check of the ELECTROLYTES, CBC, which will check blood cells, and an ALT, ALKP, CREA, GLU, TP, and BUN, which will check blood glucose, kidney and liver enzymes.These blood tests will help us to assess the health status of your pet more completely and determine if there are any additional precautions we need to take before surgery. We highly recommend a blood profile for animals over 5 years of age and is required for animals over 7 years. There is an additional charge of $88.05 for these blood tests. We hope you understand the need for these important tests.
Yes
No
I fully understand the risk of anesthesia and the importance of pre-surgical blood work to determine any underlying problems. I will not hold Midlothian Veterinary Clinic responsible if I choose to decline to run pre-surgical blood work.
Yes, please run pre-surgical blood work.
No, I understand the risk of anesthesia.
No, Patient has had labwork within the last 30 days.
I am the owner, or representative of the owner, of the animal presented and have the authority to execute this consent. I understand that current vaccinations (including Bordetella) are required for all pets entering the hospital. If vaccinations are not current, they will be updated at the doctor's discretion. I have been advised as to the nature of the procedures and the risks involved. I realize that the results cannot be guaranteed. I hereby consent and authorize this hospital to perform the above anesthetic and procedures and/or surgery. I understand the doctor and staff will use all reasonable precaution against injury, escape and/or death of my pet. I understand that all anesthetics involve some minimal risk to my pet and I will not hold the doctor or staff responsible under any circumstances. I understand that I assume all risks.
Yes
No
Microchip Implantation $63.66
Yes
No
Laser Therapy (Post-Op) $14.29
Yes
No
Please leave this field empty.
Please leave this field empty.
Close
Font Resize
A-
A+
Keyboard navigation
Readable Font
Underline links
Highlight Links
Clear cookies
Images Greyscale
Invert Colors
Close
Accessibility by WAH
