SX Consent Form in Spring, TX | Rayford Animal Wellness Clinic

Today's Date*

Client's Name*

First Last

Phone*

Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Pet's Name*

Pet's Age*

Pet's Weight (lbs)*

Breed*

Color/markings*

Pet's Gender*

Female
Male
Unknown

Organization*

ID #

Planned Procedure*

Estimated Cost

*NOTE: With any surgical procedure, we highly recommend taking home an E-collar. This will aid in the healing process by restricting pet from agitating the incision.

Would you like an E-collar?*

Yes ($20)
No

Around what time did your pet last eat? (10-12 hour fast required)*

List ALL pertinent, previous, or ongoing health concerns (please include any drug or vaccine reactions in past, vomiting, diarrhea, coughing, sneezing, nasal discharge, in-appetence, or weight loss in last month):*

Is your pet on any medications (include flea and heartworm meds)?*

Yes
No

Date last given?

***If fleas are present, flea medication will be administered at the cost of the owner. Discounts available if prevention is purchased/taken home. (Capstar (lasts 24 hours) = $10, Advantage Multi (lasts 30 days) = $20)

Optional Services at additional charge:

***We require proof of a Rabies Vaccine for ALL cats and dogs. If no proof is given, the vaccine will be administered for an additional cost of $17.00.

Do you want pre-op lab work for your pet ($100)*

Yes
No

*If pet is over the age of 8 blood work is required. For the safety of your senior pet, RAWC will not perform surgery if declined.

By signing this document, I authorize Rayford Animal Wellness Clinic to perform the procedure listed above. I understand that with any surgery there is the inherent risk of anesthesia and surgical complications which could be fatal. I do not hold Rayford Animal Wellness Clinic liable for any unforeseen complications.

***NOTE: Each pet must be in their own separate crate, trap or on a leash. Due to limited kennel space, all small animals will be returned to their crate for recovery. This creates less stress for the pet being in a familiar environment. Once the pet is in the crate a technician will monitor vitals until they are alert enough to go home. In extreme feral cases we will not be able to handle the pet once they are awake from nesthesia. WE ARE NOT IN THE CLINIC OVERNIGHT, IF YOUR PET MUST STAY WITH US, WE WILL MONITOR BEFORE LEAVING IN THE EVENING, AND AGAIN FIRST THING IN THE MORNING.

Owner's Signature*

Signature Date*
MM slash DD slash YYYY

Name
This field is for validation purposes and should be left unchanged.