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(618) 533-3042
8220 Shattuc Road, Centralia, IL 62801
crookedcreekanimalhospital1@gmail.com
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General Surgery Consent Form
Name
*
First
Last
Email
*
Pet Name
*
Does your pet have a history of seizures that you are aware of?
*
Yes
No
Is your pet current on his/her rabies vaccine?
*
Yes
No
No, but I would like to get that updated while they are in the office
Is your pet current on his/her distemper parvo vaccine? (canine only)
*
Yes
No
No, but I would like to get that updated while they are in the office
Not Applicable - Cat
Is your pet current on his/her feline distemper vaccine? (feline only)
*
Yes
No
No, but I would like to get that updated while they are in the office
Not Applicable - Dog
I need FVRCP/FELV combo vaccine because it goes outdoors or has access to outside cats
Has your pet had a heartworm test in the last 2 years? (canine only)
*
If your pet has not had a heartworm test in the last 2 years and they are older than a year, it is recommended.
Yes
No
No, but I would like to get that updated while they are in the office
Not Applicable (dog less than a year old or cat)
Do you want the mass/tumor examined by a pathologist for diagnosis?
*
Yes
No
Not Applicable
For dentals only: Do you give us permission to pull teeth if needed?
*
Yes
No
Not Applicable
Geriatric Portion of Consent Form
If your pet is 7 years old or older, please answer the following question, if not, check decline and go to section 3.
Would you like bloodwork done for your animal?
We recommend all geriatric patients (older than 7 years) that are admitted for surgery or undergoing anesthesia have bloodwork to screen for pre-existing internal issues that may not be evident physically but could possibly lead to complication while under anesthesia.
Pre-Anesthetic - Check vital liver and kidney values (most common for healthy patients)
General (Comprehensive) - breaks down liver and kidney values in to more in-depth information
Decline
General Questions
Applicable to surgery patients of all ages.
Is there anything else your animal needs while they are in the office (ie. simparica trio, interceptor plus, heartgard, revolution)? Please explain what you are needing in the answer line below. If you don't need anything just put "no".
What is a good phone number to reach you at between the hours of 9 and 5 for emergencies?
Do you consent to have a surgical procedure requiring anesthesia performed on the above animal?
*
I Consent
Δ
Home
About Us
Team
Promotions
Careers
Surgical Consent Form
New Clients
New Client Registration Form
Services
Wellness & Vaccination
Preventive Services
Medical Services
Surgical Services
Nutritional Counseling
Pet Supplies
Additional Services
Pet Health
Pet Health Library
How-To Videos
Pet Health Checker
Pet Food Recalls
Product Recalls
Pet Insurance
Payment Options
Pet Portal
Refill Requests
Pharmacy
Contact
Request Appointment
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