780-250-1700
2531 – 17th Street NW Edmonton, AB
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General Anesthesia Consent
Euthanasia Consent Form
Echocardiogram – Drop Off Consent Form
Drop Off Consent Form – with sedation
Drop Off Consent Form
Overnight Hospitalization – Drop Off Consent Form
Blood Glucose Curve – Drop Off Consent Form
Dental Surgery Consent Form
Spay/Neuter Surgery Consent Form
Telemedicine Consent Form
Ultrasound Consent Form
Admission Forms
Canine Patient Admission Form
Feline Patient Admission Form
Recheck Exam Admission Form
Questionnaires
Diarrhea Questionnaire
Vomiting Questionnaire
Itching Questionnaire
Canine Cognitive Dysfunction Syndrome Assessment
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Spay/Neuter Surgery Consent Form
Please fill out ALL fields below before your pet's surgery appointment.
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Email
*
Phone
*
Pet Name
*
Breed
*
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*
Age
*
Please specify weeks/months/years
*
Weeks
Months
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Sex
*
Male
Neutered Male
Female
Spayed Female
Consent
*
I consent that patient has not had anything to eat past 10pm the night before the procedure
Time Pre-visit pharmaceuticals were given (if they were prescribed prior to this appointment)
*
Medications my pet is on and last time given
*
Previous issues under anesthetic (please elaborate)
*
Health concerns the doctor should be aware of (please elaborate)
*
Today, my pet also needs:
*
A microchip ($46)
Vaccinations
Deworming medication (price is dependant on weight of animal)
Extraction of retained baby teeth
DOGS ONLY - Floppy rear dewclaw removal
None of the above
Please only select the fields below if your pet requires these additional services today. An estimate will be provided for you before we proceed with these additional services.
Consent
*
I have been offered pre-anesthetic bloodwork: Bloodwork checks kidney and liver enzymes. These blood tests will help us assess the health status of your pet more completely and determine if there are any additional precautions we need to take before surgery.
I have declined pre-anesthetic bloodwork
Consent
*
An IV catheter placement is REQUIRED for all anesthetized/surgical patients regardless of age. This placement allows the veterinary staff to administer fluids to maintain hydration and blood pressure. This also allows us quick access to veins in case of an emergency situation. A small patch of fur will be shaved on either the forearm or the back legs in order to do so. This is not optional, it is a required protocol here at Tamarack Veterinary Clinic.
Consent
*
I feel that the risks of surgery and anesthesia have been properly explained to me
The risks have not been properly explained
Consent
*
I would like to speak to the doctor before my pet goes into surgery as I have further questions
I have no further questions
Consent
*
There will be an additional charge for animals that are in heat, pregnant or excessively overweight and are undergoing a spay/neutering surgery.
I do not consent to additional charges for pets in heat, pregnant or excessively overweight
Consent
*
We are a Fear Free Certified Clinic that aims in reducing fear, anxiety and stress in our patients. If we notice that your pet is showing any signs of these, we automatically request that your pet receives some anti-anxiety/calming medication prior to their sedation. (Please be aware that you are responsible for the costs of this – it varies depending on weight of animal and breed.)
I do not consent to Fear Free methods
Consent
*
I, the undersigned, do hereby certify that I am the owner (duly authorized agent for the owner) of the animal described above, that I do hereby give Suzanne Misiaszek DVM, her associate doctors, agents, employees, students and/ or representatives full and complete authority to perform the surgical procedure described as above
I do not provide consent to the doctors to perform the procedures as described above
Consent
*
FURTHERMORE, I UNDERSTAND THAT DURING THE PERFORMANCE OF THE PROCEDURE(S) THAT I HAVE AUTHORIZED, UNFORESEEN CONDITIONS MAY ARISE. THEREFORE, I HEREBY CONSENT TO AND AUTHORIZE THE PERFORMANCE OF SUCH PROCEDURES AS ARE NECESSARY IN THE EXERCISE OF THE VETERINARIANS PROFESSIONAL JUDGMENT. I ALSO DO HEREBY ACKNOWLEDGE THAT I UNDERSTAND THAT THERE ARE NO GUARANTEES EITHER EXPRESSED OR IMPLIED THAT THE PROCEDURES AUTHORIZED WILL BE WITHOUT COMPLICATIONS FROM UNEXPECTED EVENTS BEYOND THE VETERINARIANS AND HOSPITAL’S CONTROL.
I do not consent to the unforeseen risks involved with this procedure
Should my pet have problems under sedation I would like:
*
CPR initiated (I understand that I will be responsible for the costs of doing so. Can range from $300-$600. If CPR initiation is not successful, you are still responsible for the costs.)
No CPR
Do you have pet insurance, if so, what company?
*
Please list the policy number.
*
Signature
*
Date
*
Date Format: MM slash DD slash YYYY
Best phone number to contact you during the time of appointment
*
Home
Contact
New Clients
What to Expect
New Client Registration Form
Prescription/Food Refill Request
About Us
Team and Pet Bios
Location & Hours
Make an Appointment
Fear Free Clinic
Services
Medical Services
Surgical Services
Anesthesia and Patient Monitoring
Nutritional Counseling
Additional Services
Pet Health
Pet Health Library
Pet Health Checker
How-To Videos
News
Forms
Consent Forms
General Anesthesia Consent
Euthanasia Consent Form
Echocardiogram – Drop Off Consent Form
Drop Off Consent Form – with sedation
Drop Off Consent Form
Overnight Hospitalization – Drop Off Consent Form
Blood Glucose Curve – Drop Off Consent Form
Dental Surgery Consent Form
Spay/Neuter Surgery Consent Form
Telemedicine Consent Form
Ultrasound Consent Form
Admission Forms
Canine Patient Admission Form
Feline Patient Admission Form
Recheck Exam Admission Form
Questionnaires
Diarrhea Questionnaire
Vomiting Questionnaire
Itching Questionnaire
Canine Cognitive Dysfunction Syndrome Assessment
Shop Online
Contact Us
Name
*
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Last
Email
*
Phone
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Pet Name
*
Preferred Date
*
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DD
YYYY
Preferred Time
*
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Reason for appointment
*