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Home » Surgical Authorization Form

Surgical Authorization Form

Click here to print and fill out the Surgical Authorization Form

Owner(Required)

First

Last

Pet Name(Required)

Date(Required)

MM slash DD slash YYYY

Procedure

Phone Numbers for Today(Required)

Pre-Surgical Bloodwork:

We recommend a pre-surgical blood chemistry panel on all pets prior to surgery. Abnormalities may increase surgical risk. If all the tests
are normal, it does not guarantee that your pet will not have an anesthetic reaction, but it does tell us that your pet is healthy and in a low
risk category.

For pets UNDER 7 years of age, the cost for this profile is $133.00.
For pets OVER 7 years of age, the cost for this profile is $175.00.

Please Select:

YES, I want the blood panel

NO, I do not want the blood panel

Pain Management:

Injectible and oral pain medication is available for your pet. Patients with proper pain management can recover quicker and with fewer
complications. **Pets over 50 pounds may have additional cost (+ $20-50)**

PLEASE SELECT:

YES, I want surgical pain medication/injection (The cost is $25-50)

YES, I want post-surgical pain medication (The cost is $25-50)

NO, I decline both pain options for my pet.

When possible, do you prefer?

Liquid

Tablet

Consent(Required)

If my pet is in heat, pregnant or has an abnormal uterus, I understand there is an additional $35.00 to $75.00 fee in addition to the surgery cost.

Consent(Required)

If my pet has retained baby teeth, I authorize the extraction of these teeth. If not extracted, these teeth can cause significant dental disease. These fees can range from $20 to $50 depending on the number of retained teeth present.

Consent(Required)

If my pet is found to have fleas or ticks , I understand they will be treated at my expense.

Consent(Required)

FOR DENTALS: I authorize the extraction of any teeth the doctor feels need to be removed. I understand there will be additional cost for these extractions. These fees can range from $50.00 to $200.00.

Consent

Initial here if we can use your pet on social media.

While your pet is in the clinic, would you like any of the following services performed:

Feline Leukemia AIDs Test $56

Yes

Genetic Health Analysis $255

Yes

Vaccinations (ask for cost)

Yes

Histopathology $185+

Yes

Heartworm Test $48

Yes

Microchip $60

Yes

E-Collar $15-30.00

Yes

IV Catheter & Fluids $120

Yes

Torigen & Histopath $250+

Yes

Radiographs $164+

Yes

Authorization to Perform surgery and/or treatment(Required)

I hereby authorize Key City Veterinary Clinic to perform such diagnostic, therapeutic and surgical procedures as described above. The nature of such services has been described to me to my satisfaction and I realize that no guarantee nor warranty can ethically or professionally be made regarding the results or cure. I also authorize the clinic staff in an emergency situation, to follow through with such procedures as are necessary for the well being of my pet on a continuing basis until further communication with me. I understand that I assume financial responsibility for all services rendered.

Signature(Required)

Print Name(Required)

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Abilene, TX 79602

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318 E. South 11th St.,
Abilene, TX 79602

About Us
Forms
Services
Emergencies
Online Store
Contact Us

Business Hours

Monday

7:30am – 5:30pm

Tuesday

7:30am – 5:30pm

Wednesday

7:30am – 5:30pm

Thursday

7:30am – 5:30pm

Friday

7:30am – 5:30pm

Saturday

Closed

Sunday

Closed

Appointments recommended. For after hours emergencies call (325) 691-1504