Surgery Consent Form

Name: Rouse Hill Family Veterinarian
Address: 10/591 Withers Road, Rouse Hill, NSW, 2155, Australia
Telephone: 02 9086 9130
Price range: $

APPOINTMENT

Please fill out this form as completely and accurately as possible before your pet’s procedure. If you have questions, don’t hesitate to give us a call at 02-9086-9130.

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email Address *

Mobile Phone Number *

Additional contact number:

Pet Information

Pet's Name *

Species *

Breed *

Colour: *

Date of Birth/Age:

Sex *

Desexed *

Weight

Procedure

Do you agree to your pet having a preanaesthetic blood test run? *

YES I agree to the preanaesthetic blood test costing $150 - $183.50 depending on my pet's age
NO I decline my pet having a preanaesthetic blood test today. The risks have been explained to me and I understand them.

Additional Procedures

Ear examination (no charge) *

Nail Trim (no charge) *

Occasionally a side effect of the anaesthetic is nausea. If you pet is feeling nauseous after the procedure we recommend providing them with a anti-emetic injection called cerenia. Would you be happy to proceed with the injection if we feel necessary? The cost varies on your pet's weight from $38 - $108. *

I give permission for Rouse Hill Family Vets to post pictures or videos of my pet on their social medial platforms (Facebook, Instagram, TikTok, YouTube and their website). *

We recommend laser therapy in recovery and at the 3 day post op check to help with wound healing and reduce pain and inflammation. The price of this is $22. Would you like to go ahead with this? *

Read more about K-Laser Therapy

I understand that while every care will be taken, there is always some degree of risk involved with any medical or surgical procedure, and that I have discussed any concerns I may have with the veterinarian and herby release, discharge and indemnify the veterinarian and any person or corporation associated with the hospital from all actions, suits, demands, claims, causes of action and costs of every description whatsoever at law, equity and under statue which I being the owner of this pet or person authorised by the owner, or any other person or corporation has, may have had or but for this consent could, would or might at any time hereafter have against the veterinarian or any person or corporation associated with the hospital in respect of or arising directly or indirectly out of the medical or surgical procedure. *

I understand

I am also aware that full payment is required at the time my pet is discharged from hospital. In the case of extended hospitalization/treatment, further costs may be incurred, and it may become necessary for me to make further payments before my pet's discharge date. The veterinarian on duty will inform me if this becomes necessary. *

I understand

I, the undersigned, being over the age of Eighteen (18) and the owner of the above pet or a duly authorised agent, have read the above information and the terms and conditions (below), and do hereby give my consent for the above-mentioned surgical treatment, and any other procedure that should become necessary, at Rouse Hill Family Vets. *