Chicago Cat Clinic

Surgery Consent Form

Save time during your next appointment! Complete your required surgery consent form online from any device at any time before your visit.

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Surgery Consent Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit If this is an emergency of is your pet needs urgent care, please call us at 773-631-5300 for a faster response.

Date *

Owner's Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Pet's Name *

Preferred Phone *

Secondary Phone

Email *

Please be available to us today while your pet is here. In order to minimize the length of time your pet is under anesthesia; we will limit the time that we attempt to contact you to 5 minutes. It's important that you have your phone accessible to you today so that we can reach you if necessary. How do you prefer that we contact you, phone or text? *

Phone
Text

I hereby authorize performance of the following surgical or other procedure(s): *

Multiple Choice *

I understand that during the performance of the foregoing procedure(s) or operations(s), unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure(s) or operation(s) than those set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) or operation(s) if necessary and desirable in the exercise of the veterinarian’s professional judgment.

Multiple Choice *

I also authorize the use of appropriate anesthetics and other medications, and I understand that hospital support personnel will be employed as deemed necessary by the veterinarian.

Multiple Choice *

I understand that I assume financial responsibility for all services rendered and that payment is due on the date of the surgery.

Please list any other procedures you want to have done today:

PREOPERATIVE BLOOD PANEL

Like you, our greatest concern is the health and well-being of your pet. Because your pet cannot describe symptoms to let us know what might be wrong, we run blood tests to give us the answers we need, especially before surgery. By testing blood chemistries, we can evaluate the status of your pet’s major organs. The latest in technology has enabled us to run blood chemistries quickly and accurately before anesthetic induction. Senior pets (those 8 and over) are required to have this test done prior to any anesthetic procedure.

The Prep Profile II provides six chemistry values, which evaluate the liver, kidneys, and detect anemia and diabetes. Includes ALP, ALT, BUN, CREATININE, GLUCOSE, TOTAL PROTEIN, PACKED CELL VOLUME. *

The doctor has determined that this procedure will require a Prep Profile II.
My pet recently had the appropriate blood chemistries run.
Yes, I want the Prep Profile II blood tests run.
No, I do not want my pet to have the Prep Profile II blood tests run.

IV FLUIDS

We require fluid therapy for any patient undergoing a general anesthesia for dental procedures. Fluid therapy is an important element of anesthetic patient management because it helps: *

Maintain hydration
Maintain blood pressure
Provide ready access to a vein for medication

Until your pet learns to use the phone, a microchip will help him find his way home! *

Yes, I would like my pet to be protected with a microchip.
No, I do not want my pet to have a microchip today.
My pet already has a microchip.

Chicago Cat Clinic

Surgery Consent Form

Online Forms

Surgery Consent Form

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