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General Surgical Consent Form

Please complete all required fields below. This form requires your consent for surgical procedures at Blue Diamond Animal Hospital. Ensure all information is accurate and all required checkboxes are marked before signing.

37 questions across 6 sections.

Leave this field empty:

Fields marked with an asterisk are required.

Sections

About you 4
Visit details 4
About your pet 8
Medical history 14
Consent and authorization 6
Sign and submit 1

Some answers still need attention

About youSection 1 of 6

New Client Status * (required)Please complete our New Client Form before your visit

YesNo

Owner's Name * (required)

Best Phone Number to Contact After Procedure * (required)

Email * (required)

Visit detailsSection 2 of 6

Surgery Being Performed * (required)

Today's Date * (required)Format: MM/DD/YYYY

Date of Procedure * (required)Format: MM/DD/YYYY. Please Note We Do Not Operate on Sundays

Date of Signature * (required)Format: MM/DD/YYYY

About your petSection 3 of 6

Pet's Name * (required)

Pet's Gender * (required)

MaleMale (Neutered)FemaleFemale (Spayed)

Is This a New Pet? * (required)

YesNo

Species * (required)

DogCat

Breed * (required)

Color * (required)

Age/Date of Birth * (required)

Microchipped? * (required)

YesNo

Medical historySection 4 of 6

Last Heat Cycle or Pregnancy Status * (required)Pregnant or patients in heat will be subject to additional fees due to the increased complexity of surgery ($70)

Previous Clinic Name

Previous Clinic Phone

Request Medical Records?

YesNo

Previous Illnesses or Surgeries? * (required)

YesNo

If Yes, ExplainOnly required if previous illnesses or surgeries selected

Special Diets or Medications? * (required)

YesNo

If Yes, List Medications/DietsOnly required if special diets or medications selected

Medication Received This Morning? * (required)

YesNo

What Medication?Only required if medication given this morning

Dog VaccinesSelect all that apply

DHA2PParvoBordetellaRabiesFecalCoronaBiv Influenza

Cat VaccinesSelect all that apply

FVRCPFeLVRabiesFecal

Current Medications List * (required)Please list the medications your pet is currently taking (including name and dosage)

Medication Given This Morning (Confirmation) * (required)

YesNo

Consent and authorizationSection 5 of 6

Acknowledgment of Heat/Pregnancy Surcharge * (required)Must be checked if pet is pregnant or in heat

I have read and understand

VGAL Staff Acknowledgment * (required)Blue Diamond Animal Hospital staff Veterinary Graduates Awaiting Licensure (VGAL). While they possess the necessary skills and knowledge, it is essential to acknowledge that their licensure is pending. The well being of the animal remains the primary concern. I'm aware of this arrangement and provide consent to proceed.

I have read and understand

Pre-Surgical Blood Profile Acknowledgment * (required)We require a blood profile for animals older than seven years.

I have read and understand

CPR Authorization * (required)Your pet may require cardiopulmonary resuscitation (CPR), including cardiac compressions, positive pressure respiration, emergency medications, or other interventions.

I authorize CPRI do not authorize CPR

Surgical Consent Statement * (required)As the owner or agent of the above animal, 18 years of age or older, I hereby give my consent to Blue Diamond Animal Hospital to perform a surgical procedure on my pet.

I consent

Authorization & Consent Acknowledgment * (required)Full legal acknowledgment of authorization

I have read and understand this authorization and consent. I further understand that I assume financial responsibility for all services rendered.

Sign and submitSection 6 of 6

Digital Signature * (required)Typing your full name here counts as your signature.

Please read before you submit

FULL SURGICAL CONSENT AND AUTHORIZATION As the owner or agent of the above animal, 18 years of age or older, I hereby give my consent to Blue Diamond Animal Hospital to perform a surgical procedure on my pet. I understand that during the performance of the procedure, an unforeseen situation may arise that necessitates an extension or variance in the procedure set above. I hereby authorize Blue Diamond Animal Hospital to use reasonable care and judgment in performing the procedure. I further understand that I assume financial responsibility for all services rendered. I understand that all pets presented to Blue Diamond Animal Hospital for a procedure must be current on vaccinations. ANESTHESIA AND CPR PROCEDURES: Your pet may require cardiopulmonary resuscitation (CPR), including cardiac compressions, positive pressure respiration, emergency medications, or other interventions. PRE-SURGICAL BLOOD PROFILE: We require a blood profile for animals older than seven years. VETERINARY GRADUATES AWAITING LICENSURE (VGAL) STAFF ACKNOWLEDGMENT: Blue Diamond Animal Hospital staff Veterinary Graduates Awaiting Licensure (VGAL). While they possess the necessary skills and knowledge, it is essential to acknowledge that their licensure is pending. The well being of the animal remains the primary concern. I'm aware of this arrangement and provide consent to proceed. HEAT CYCLE AND PREGNANCY SURCHARGE: Pregnant or patients in heat will be subject to additional fees due to the increased complexity of surgery ($70). I have read and understand all terms and conditions of this authorization and consent form.

I have read and agree to the terms above. * (required)

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Call us and we will sort it out with you. We are open seven days a week.

Book a visit Call 702-944-8440