Dauphin Vet Clinic

PO Box 556
Dauphin, MB R7N 2V4

(204)638-3044

dauphinvetclinic.com

Canine Surgery Consent Form

Name (required)
First Name (required)
Last Name (required)
Pet's Name (required)

Phone (required)
Phone TypePhone Number (required)
Address
Street Address
City
,
State / Province
Zip / Postal Code
Date of appointment (needs to be booked already): (required)

Appointment scheduled for (required)
Dauphin Veterinary Clinic
Ste. Rose Veterinary Clinic


E-Mail Address (required) :
Pre-surgery Health Questions
Has your pet had any issues with vomiting or diarrhea? Or coughing or sneezing lately? Is your pet currently on any medications? Do you have any health concerns of your pet that we should be aware of?
Health comments:

Surgery (please select one) (required)
Canine Neuter $198 (Cryptorchid $285)
Canine Spay $285 (add $35 if pregnant, obese, in heat, mature)
Other procedure
Continue if pregnant? (required)
Yes
No


Other Procedure?

Pre-Anesthetic Blood Testing:
We strive to practice quality medicine. We STRONGLY recommend that pets have their blood screened before anaesthesia, just like people do. Blood work can warn us about underlying conditions that could lead to possible complications. We look for kidney and liver problems, as well as anaemia or low platelets which affect blood clotting and signs of infection.
Please select an option: (required)
Comprehensive Panel and CBC ($109.97)
Coagulation Panel (tests for blood clotting disorders, bleeding problems, $65.51)
Heartworm 4DX (Looks for heartworm, Lyme and Ehrlichiosis $54.99)
No, I refuse any blood testing on my pet
IV Catheterization
When accepted, an IV catheter will be placed prior to your pet being placed under anaesthesia. This helps support blood pressure, kidneys and liver, and keeps your pet hydrated. In the unlikely event of a crisis during anaesthesia, this will also allow for medication to be administered rapidly. Cost is $60 above the surgery price. (*Note: selected surgeries performed have mandatory IV catheterization and is at the discretion of the Veterinarian.)
Please select: (required)
Yes, I have ACCEPTED the IV catheterization
No, I DECLINE the IV catheterization


Laser Therapy **New (Dauphin Only)
Laser Therapy decreases pain and inflammation, so can be applied to surgical incisions at the time of surgery. Laser therapy compliments the other modes of pain management. Please ask us if you have questions. (Cost is $20)
Laser Therapy for the incision (Only available in Dauphin) (required)
Yes
No


Pain Management
We strongly believe in alleviating pain in our patients. We routinely give pain control medications at the time of surgery (included in surgery price). In some cases, pets require pain medications after surgery, to be given over a few days to make the pet more comfortable (not included in surgery price).
Please check if you wish your pet to go home with extra pain medication. (required)
Yes, I ACCEPT extra pain medication
No, I DECLINE extra pain medication


Microchip and Tattooing
A microchip or tattoo can help return a lost pet to the owner. A microchip is placed under the skin and is permanent and a tattoo is placed in the right ear, is visible, but could fade over time. A tattoo is free with a spay or neuter. A microchip has an additional cost of $33.25.
Tattoo (free) (required)
YES
NO


Microchip ($33.25) (required)
YES
NO


Vaccination
Is your pet up to date on vaccinations? If accepted, we will vaccinate your pet after surgery. **City of Dauphin By-Law states that all pets must be vaccinated for Rabies yearly. You may decline vaccinations at this point but please be advised that to have your pet licensed, they will need to return at some point to be vaccinated.
Please select: (required)
Distemper Combo ($67.50)
Rabies only ($67.50)
Distemper Combo and Rabies ($72.50)
No, I DECLINE vaccinations
Deworming
Cost is dependent on the weight of the pet. **If parasites are found on your pet while visiting our facility, we will treat the pet with the necessary treatment at the owner's expense for the protection of your pet and that of others in the hospital.
Please select: (required)
Yes, I ACCEPT deworming
No, I DECLINE deworming


Any other procedures or comments?

Pictures
Pictures may be taken of your pet that could be used for the clinic website or Facebook or presentations. Do you give your consent to the use of pictures?
Please indicate: (required)
YES
NO


Phone # during procedure (required)
Phone TypePhone Number (required)
Acknowledge
Doctors and staff are not present at the clinic 24 hours a day. Payment is expected at the time of service. We accept cash, cheque, Debit and Credit Card. By clicking Submit below, you are acknowledging this information and verifying that the above information is correct to the best of your knowledge.

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