Address: 235 South Av Poughkeepsie, New York 12601-4815

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Surgical Consent Form

Thank you for giving Poughkeepsie Animal Wellness the opportunity to care for your pet(s). Please help us better meet your needs by taking a few moments to fill out this form before your visit.

doctor do surgery

Client Name *

Date *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Cell Phone *

Email Address *

Patient Name *

Breed *

Species *

Age *

Sex *

Color *

Last time food was given to the patient: *

Is your pet showing any signs of illness? *

Yes
No

If YES, please list below *

Is your pet on any medication? *

Yes
No

If YES, please list below *

Has your pet had any surgeries in the past? *

Yes
No

If YES, please list below *

Has your pet had any previous reactions to anesthesia? *

Yes
No

Is your pet currently in heat? *

Yes
No

Has your pet previously gone into heat? *

Yes
No

If YES, when was the last cycle? *

Does your pet currently have fleas?

Yes
No

Pets With Fleas Will Receive Flea Treatment at the Owner's Expense

Authorization

I, the undersigned, do verify I am the owner (or authorized agent for the owner) of the above-named pet and authorize the above procedure to be performed. I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure(s) as directed by the veterinarian. *

I have read and understand

I, the undersigned, have been advised as to the nature of this procedure to be performed and the risks involved. I understand also that there is always a risk associated with any anesthesia episode, even in apparently healthy animals and I have discussed my concerns with the veterinarian. I understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated for the safety or care of my pet. *

I have read and understand

I, the undersigned, do hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian’s professional judgement. I accept responsibility for any result in additional charges. *

I have read and understand

I, the undersigned, agree to be responsible for any charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital. I understand no staff will be attending to my pet overnight (pets needing special care may be referred to a 24-hour hospital.) *

I have read and understand

Signature *

Clear Signature

Pregnancy

If we find that your pet is in EARLY stages of pregnancy during the surgery, would you like us to continue with the surgery and abort the pregnancy? *

Yes
No

Baby Teeth

At approximately 6 months of age, most cats and dogs typically have lost all baby teeth which have been replaced by the adult teeth. In some cases, especially small or toy breed dogs, the adult tooth has erupted, but the baby tooth is still present. These retained teeth can cause significant dental problems down the road. It is recommended, at the time of spay and neuter to have these retained baby teeth removed as the pet is already under anesthesia. If upon exam, we find that your pet has retained teeth, would you like us to remove them. The additional cost will range between $50.-$150 depending on how many teeth need to be extracted. *

Yes
No

Payment

Payment for today is due in full at the time of drop off. We DO NOT accept checks, nor do payment plans. Cash, Credit, and Care Credit are accepted.

Print Name *

Date *

Signature

Clear Signature

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Pre-Anesthetic Bloodwork

Pre-anesthetic bloodwork checks the internal organs as well as a blood cell count. This is a vital part of having a safe anesthetic procedure. Help us provide the best level of care for your pet by choosing to perform bloodwork prior to anesthesia or sedation. *

Mini Chemistry $114.50
Bloodwork was already done upon booking surgery.
I decline bloodwork & understand the possible risks anesthesia may have on my pet.

Signature

Clear Signature

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Contact Information

Phone: (845) 473-0358

Address: 235 South Ave
Poughkeepsie, New York 12601-4815

Phone: (845) 473-0358

Address: 235 South Ave
Poughkeepsie, New York 12601-4815

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

Business Hours

Monday8:00 am – 6:00 pm

Tue, Thu8:00 am – 5:00 pm

Wed, Fri8:00 am – 6:00 pm

Sat – SunAppointment Only

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