Client # Consent Form For OvariohysterectomyOwner Date MM slash DD slash YYYY Patient Age Breed Sex Colour Procedure(s) Ovariohysterectomy (spay) I hereby certify that I am the owner or the owner’s agent of the above named cat and have the authority to authorize the above named procedure(s), the performance of which are hereby authorized. As part of the named procedure(s), I consent to blood and/or tissue sampling, medically diagnostic or photographic imaging, or other reasonable and non-harmful testing that may be of educational or investigational value to my cat or to other cats. I recognize that the above listed procedure(s) carry a small but realistic possibility of complications and side-effects that may include death. I agree to hold the staff of Alamo Feline Health Center blameless for all complications in the absence of gross malpractice. I authorize the use of such anesthetic or sedative agents deemed advisable in the performance of such surgical, diagnostic, or therapeutic procedure(s). I realize that the administration of any anesthetic or sedative agent carries a small but realistic possibility of side-effects that may include death. I realize that complications can occur due to pre-existing conditions or conditions not evident during physical examinations, blood tests, and other diagnostic tests. I agree to hold the staff of Alamo Feline Health Center blameless for all complications in the absence of gross malpractice. To minimize problems, we recommend that your cat be screened prior to this procedure with a Blood Screen. This important test evaluates kidney and liver function, as well as blood glucose and red blood cell count. The liver and kidneys play an important role in the breakdown of anesthetic drugs in the body. The level of glucose is important in making sure they have adequate energy storage to handle anesthetic drugs. Red blood cells carry oxygen from the lungs to the body. This test is an additional $57.15 or $77.75 based on the condition of the patient as determined by the doctor. I authorize that this test be performed on my cat: YES NO (Please select one) Yes No Microchip Placement: A microchip is a tiny computer chip which has an identification number programmed into it. This microchip is encapsulated within biocompatible material. The chip is so tiny it fits through a hypodermic needle and can be simply injected under the skin of your cat. This provides a permanent and positive identification, which cannot fade or fall off. It is a safe, simple, and inexpensive way to protect your cat against loss or theft. This procedure is an additional $49.10.I want this procedure performed on my cat: YES NO (Please select one) Yes No I understand that if my cat is found to be in heat (estrus) or pregnant, causing the procedure to be more involved due to the engorgement of the tissues and larger blood vessels, I will be charged additionally, as follows: In heat: $14.10 Pregnancy: $27.55 to $66.40 Initial Signature of owner or agentPhone number(s) where owner can be reached for additional information:Phone #:Times Available: Phone #:Times Available: I agree that if a change is needed in the performance of the procedure(s) stated above or an additional procedure(s) is needed and an unsuccessful attempt is made to reach me at the phone number(s) above, the staff of Alamo Feline Health Center has my permission to proceed accordingly, using their best judgment, and I will be responsive for any additional charges incurred.ACCEPT REJECT
