Healthcare Spay Estimate

HEALTHCARE SPAY ESTIMATE

Clinic Name:     Prepared By:     Date Prepared:

Patient (Animal) Information

Species/Breed:     Sex:     Age/DOB:     Weight (lbs/kg):

Owner / Client Information

Phone:     Email:     Emergency Contact:

Insurance Information (if applicable)

Policy / ID #:     Group #:     Subscriber Name:

Medical History & Current Status

Procedure Estimate — Itemized

Procedure: Ovariohysterectomy (Spay) — estimated routine elective procedure for sterilization of female patient.

Estimated Total (not final):     Deposit Due at Admission:     Payment Method Accepted:

Pre-Operative Instructions (Summary)

NPO Instructions: Do not feed solid food after midnight prior to surgery. Water may be offered until the morning of admission unless otherwise directed.

Risks, Benefits and Alternatives

I understand that spay surgery (ovariohysterectomy) is performed under general anesthesia. The expected benefit is sterilization and prevention of reproductive-related diseases. Known potential complications include, but are not limited to: anesthetic reaction, hemorrhage, infection, seroma, wound dehiscence, and death. Unforeseen complications may require additional treatments and costs. There are no guarantees as to outcome.

Alternatives to spay include surgical sterilization at a different age or non-surgical management; refusal of surgery may result in continued estrus cycles and risk of pregnancy. If pre-operative screening reveals increased anesthetic risk, the attending veterinarian may recommend additional diagnostics prior to proceeding.

Authorization, Consent and Acknowledgement

By signing below I authorize the clinic and its veterinary staff to perform the spay (ovariohysterectomy) on the identified patient and to administer anesthesia, analgesia and medications as judged necessary. I authorize performance of reasonable radiographs, bloodwork, fluids, emergency procedures or minor additional treatments if discovered necessary during surgery to preserve the patient's life or well-being. I agree to be responsible for all charges incurred.

I acknowledge that this document is an estimate only. Actual charges may exceed the estimate due to unforeseen complications or additional treatments. Payment in full is required upon discharge unless other written financial arrangements have been approved. If the patient requires emergency care beyond the estimate and I cannot be reached, I authorize the clinic to proceed with the necessary care and I accept financial responsibility.

I authorize the clinic to humanely dispose of any tissues removed during surgery unless otherwise requested in writing prior to the procedure.

Estimate Valid For:     Additional Notes:

Acknowledgments (check all that apply)

I confirm the patient has been fasted per instructions.

I will provide accurate medication history and follow post-op care instructions.

I understand that my insurance may not cover all charges and I am responsible for balance.

Clinic Use Only

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