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Surgical Consent Form

Please fill out the following form before your scheduled appointment.

We look forward to seeing you!

Thank you for choosing Cooper Veterinary Clinic! Please fill out the following form to the best of your ability before your scheduled appointment. If you have any questions, please feel free to call us at 806-687-0687. If you would rather print and fill out the form at home, please click the button below.

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Surgical Consent Form

Client's Name *

First

Last

Email *

Phone number where owner or another responsible party can be reached: *

Secondary Phone number where owner or another responsible party can be reached: *

Patient's Name *

Breed *

Age/Date of Birth *

Sex *

Male
Male (neutered)
Female
Female (spayed)

I understand that if my pet's current Rabies vaccination is not provided; the vaccine will be administered at the time of the procedure at an additional cost. *

I understand

Patient History

Is your pet currently on vaccinations? *

Is your pet currently taking any medications, including over the counter medications and herbal remedies? *

If so please list the medications and what time it was given *

Does your pet have any seizures and/or heart conditions that we need to be aware of? *

Does your pet have any drug allergies or any complications with other procedures or anesthesia? *

If so, please list *

Procedure to be Performed *

Surgical additions:

Please select either “Accept” or “Decline” for the following services you'd like added to your pet's visit:

IV Fluids ($58.00) *

Accept
Decline

CBC (Complete Blood Count) ($53.50) *

Accept
Decline

Limited Profile ($71.50) *

Accept
Decline

Comprehensive Profile ($100.50) *

Accept
Decline

HEARTWORM 4DX (Canines) TEST or FELV/FIV COMBO (Feline) TEST ($49.50/$59.50) *

Accept
Decline

Histopathology ($384.00) *

Accept
Decline

Please SELECT one of the following: *

Should any unforeseen medical/dental procedures and emergencies be necessary and desirable in the veterinarian’s professional judgement, I prefer that the veterinarian proceed with all unforeseen incidents that happen while my pet is in the care of Cooper Veterinary Clinic. I accept all financial responsibility for all costs incurred.
I prefer to be called before any additional procedures, other than emergencies. If I cannot me reached, I do authorize the veterinarian to proceed only if there is an unforeseen treatment that is needed for my pet.
If I cannot be reached by phone, I do not authorize the veterinarian to proceed with any necessary medical procedure, including emergencies. If any unforeseen incident occurs, I release Cooper Veterinary Clinic of all responsibility.

I verify I am the owner (or authorized agent for the owner) of the pet listed above and authorize the above procedure(s) to be performed. I understand that during the procedure, unforeseen conditions may be revealed that necessitate an extension or variance in the procedure. I expect Copper Veterinary Clinic and its staff to use reasonable judgement in performing the procedures. I understand the nature of the procedures and risks involved (including death) and I realize results cannot be guaranteed. I am also aware that unforeseen events resulting from the procedure will not relieve me of my obligations to all responsible costs incurred regarding my pet listed above. I also understand that my pet will receive a tattoo for a sexual sterilization while under for a sex altering procedure, and that for most procedures, my pet will stay overnight for observation and will be ready to go home the following day. *

I authorize

Signature *

Clear Signature

Date *

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Address

12105 Indiana Ave
Lubbock, TX 79423

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Emergencies

Lubbock Small Animal Emergency Clinic
6305 66th St # 300
Lubbock, TX 79424
806-797-6483

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Email

coopervet@nts-online.net

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Phone

806-687-0687

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Hours

Mon–Wed & Fri: 7:30 am to 6 pm
Thur: 8 am – 5 pm
Sat: 9 am to 12 pm
Sun: Closed

Have a Question?

Please fill out the form below and a member of our team will get back to you shortly!

Name *

First

Last

Email *

Phone

How can we help you? *

Phone

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