Healthcare Spay Form

HEALTHCARE SPAY CONSENT AND AUTHORIZATION

Owner and Patient Information

Owner Name:   Phone:

Patient (Pet) Name:   Species/Breed:

Age or DOB:   Weight: lbs

Sex: Female Male   Color/Markings:

Emergency & Secondary Contact

Insurance and Payment

Pet Insurance Provider:   Policy Number:

I acknowledge that I am financially responsible for all charges related to the spay procedure and any additional treatments authorized under this form:

Medical History

Procedure Details, Risks, and Consent

Procedure to be performed: Ovariohysterectomy (spay) — elective surgical removal of the uterus and ovaries under general anesthesia.

I understand that risks associated with anesthesia and surgery can include, but are not limited to, anesthetic complications, bleeding, infection, adverse reaction to medications, wound dehiscence, changes in appetite or behavior, and, in rare cases, permanent disability or death. I acknowledge that no guarantee can be made concerning the results of the procedure.

I authorize the veterinarian to administer pre-operative diagnostics, anesthesia, analgesia, intravenous fluids, and such medical and surgical procedures as are necessary for the performance of the spay and for the management of complications. I further authorize the veterinarian to perform additional procedures if unforeseen conditions are discovered during surgery that, in the veterinarian's professional judgment, are necessary for the patient's welfare.

If additional procedures beyond the scope of this consent are recommended, I authorize the clinic to proceed only after reasonable effort to contact me unless delaying treatment would jeopardize the patient's health. If immediate treatment is necessary and I cannot be reached, I authorize the veterinarian to proceed as needed.

Pre-Operative Instructions

I agree to withhold food from the patient for at least 8–12 hours prior to anesthesia unless otherwise instructed by the clinic, and to withhold water for the period recommended by clinic staff. I acknowledge that deviation from these instructions may result in cancellation or increased anesthetic risk.

Additional Authorizations

Please indicate any of the following services that you authorize to be performed if recommended by the veterinarian at the time of surgery:

Microchip implantation    Vaccination(s) as indicated    Dental evaluation/extractions    Skin lesion biopsy/excision

Post-Operative Care and Acknowledgments

I acknowledge that post-operative care instructions will be provided and that I am responsible for following those instructions. I understand that normal recovery may include lethargy, reduced appetite, and mild discomfort and that I must contact the clinic if I observe excessive bleeding, swelling, difficulty breathing, persistent vomiting, or other concerning signs.

Authorization Expiration

This authorization will remain in effect until the completion of the procedure and associated post-operative care or until:

Certifications and Owner Declaration

I certify that I am the legal owner or authorized agent of the owner of the patient described above and am at least 18 years of age. I have read and understand the information and risks described in this form. I have had the opportunity to ask questions and those questions have been answered to my satisfaction. By signing below I consent to the performance of the spay procedure and any authorized ancillary treatments, and I accept financial responsibility as described above.

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