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Owner's Name

Date of Upcoming Procedure

Address

City

State

Zip

Primary Phone

Secondary Phone

Email

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It is imperative that the doctor be able to reach you by phone on the day of the surgery. After the procedure the doctor will call you to discuss surgical findings and post-operative care for your pet.

Pet Information

Pet's Name

Species

Breed

Date of Birth/Age

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Surgical Procedure

Bladder Stone Removal

A surgical cystotomy begins with pre-anesthetic bloodwork. If that comes back within acceptable limits, sedation will be administered. Your pet will be intubated and placed on anesthesia gas and IV fluids. After the surgery is performed, your pet will go home with pain medication and an e-collar, if you don't already have one.

If not already, would you like your pet microchipped today?

Would you like any expired vaccines updated?

Yes, all expired vaccines and tests
No
Only those indicated below

Additional procedures to be performed:

Please be aware that each additional treatment will be performed at additional costs that may or may not be included in your previous estimate.

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Medical Release and Authorization

I, the undersigned, do hereby certify that I am the owner, or duly authorized agent for the owner, of the animal described above and that I do hereby give Georgetown Veterinary Hospital, its veterinarians, agents and/or representatives full and complete authority to perform the surgical procedure described above. I also grant permission to perform any other procedure that, at their discretion, may be useful to promote the health of the above described pet, and I do hereby and by the presents forever release the said doctor, their agents, or representatives from any and all liability arising from said surgical procedure on said animal. I accept full financial responsibility for all tests and treatments that I verbally authorize during my conversation with the doctor. I understand that payment is due in full when my pet is discharged.

I understand that if evidence of fleas is found on my pet during the examination, a dose of “CAPSTAR” will be administered at my expense. (Approx. $8.00)

I agree to the terms stated above.

I agree.

Today's Date