Dental Surgical and Medical Consent Form

Please fill in our form below, and download it if you'd like to print it out.

Download the Form

Client:

Phone:

Patient:

DOB (mm/dd/yyyy):

Age:

Sex:

FF/SMM/N

Species:

FelineCanine

Breed:

Procedure:

Please answer the following questions:

Within the last week has your pet experienced any vomiting or diarrhea?

YesNo

Within the last week has your pet ingested any human foods or products?

YesNo

Is your pet on an NSAID or steroid (Rimadyl, Meloxicam, Prednisone)?

YesNo

Is your pet taking any other medications or supplements?

YesNo

Does your pet have any food allergies?

YesNo

Has your pet had any surgical procedures performed previously?

YesNo

Does your pet have any past or current medical conditions?

YesNo

Is your pet on a special diet?

YesNo

**If yes, please bring a small meal for your pet. Please note that raw diets are prohibited**

When was the last time your pet ate?

If you answered yes to any of the above questions, please explain:

Mendon Village Animal Hospital recommends flea/tick & heartworm preventatives to be given year-round. Lyme disease is extremely prevalent in our area.

Please answer the following regarding your pet’s current flea/tick & heartworm preventative routine.

Brand of flea/tick product currently being used

date of last dose

Brand of heartworm product currently being used

date of last dose

Do you give your permission for MVAH to post pictures of your pet on the MVAH website, Instagram or Facebook?

Yes. I authorize MVAH to share my pet’s photo & storyNo. I do not authorize this.

Would you like your pet to receive a nail trim at no additional cost?

YesNo

By checking this box, I agree that, I am the owner of the above described animal and have the authority to execute this consent. I hereby authorize the performance of the procedure(s) and/or operation(s) listed. I authorize the use of appropriate anesthetics, a pre-anesthetic health screen and other medications; and I understand that hospital support personnel will be employed as deemed necessary by the veterinarian. I also consent to treatment of any unforeseen emergency. Our hospital strongly believes in compassionate, quality medical care for our patients. Pain management is not only humane, but helps your pet feel better, and may prevent adverse medical consequences associated with uncontrolled pain. As a result, all surgical patients will receive pain management during surgery and postoperative recovery. Additionally, medication may be prescribed for use at home. I have been advised as to the nature of the procedure(s) or operation(s), and the risks involved. I realize that results cannot be guaranteed. We make every effort to provide state-of-the-art, caring veterinary services to your pet. In return, we ask that our clients pay for these services at the time they are rendered. Please indicate below what your full payment method will be for today.

Please specify who is dropping your pet off today:

Please specify who will be picking your pet up today:

Preferred method of communication:

PhoneText

Signature