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Consent For
Treatment Form

Save time during your next appointment! Complete your required consent for treatment form online from any device at anytime.

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Consent For Treatment 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.

Owner's Name *

First

Last

Pet's Name *

Phone number where I can be reached at today? *

Alternate phone number for today:

Email *

In-Patient Questionnaire

Last time food was offered to patient: *

Last time water was offered to patient: *

Has your pet had pre-surgical bloodwork done within the last 6 weeks?

Blood work is required before general anesthesia.

We will be drawing the appropriate blood work today before surgery. Please be available by phone this morning so we can contact you should there be any significant issues we need to discuss with you.

Initial

Is your pet showing any signs of illness today?

Pease tell us what is going on today! We may need to postpone the surgical procedure, depending upon what is going on. We want to keep your pet as safe and healthy as possible!

Please give details as to what is occurring - vomiting, diarrhea, itching, ear/skin infection, etc.

Please list all medications your pet is taking:

Please write N/A if your pet is not on any medications.

When was the last dose administered?

Is your pet on any heartworm or flea/tick preventative?

Has your pet had any previous reactions to anesthesia?

If your pet has had any previous reactions to anesthesia, please explain below: *

List any behavioral concerns (biting, timidness, needing special handling, etc):

List any belongings left with your pet (i.e., carrier, leash, collar, etc.):

The hospital will not be responsible for any lost items.

What type of procedure is your pet having today? Check all that apply.

Spay (females)
Neuter (males)
Mass removal
Dental procedure
Other

If 'Other', please describe: *

For mass removals, would you like the mass submitted for biopsy? This is strongly recommended.

Yes
No
I would like to discuss it with the veterinarians.

The veterinarians will call you after the procedure to discuss if the mass should be submitted for biopsy.

During spay and neuter procedures, we check to make sure there are no retained baby teeth. If there are retained teeth at the time of surgery, we recommend removing them while your pet is under anesthesia, so it does not have to be done in the future. There will be an additional fee for removing the retained tooth/teeth.

Initial

If, during surgery, it is found that my pet may be pregnant, I allow the veterinarian to proceed with the surgery as previously planned. I understand that this may add additional costs to the procedure. I DO NOT need a phone call during surgery.

True, I do not need to be contacted. Please continue with surgery.
False. I need a phone call!

I WANT A PHONE CALL during the procedure if my pet is suspected/found to be pregnant. I understand that anesthesia can be fatal to the fetuses and may lead to spontaneous abortion. I also understand that anesthesia can cause serious birth defects. I accept that if the staff of Mayfair Animal Hospital cannot reach me within 5 minutes of the initial phone call, they will continue with the surgery, and my pet will be spayed. I agree to still be responsible for any anesthesia and surgical charges. *

Initial

I accept the recommendations of the veterinarian and agree to any and all extractions that they feel are necessary. I DO NOT require a phone call before proceeding. I understand and accept that this may make my total bill higher than the signed estimate. *

Initial

I accept that dental extractions are a serious surgical procedure. Very rarely, there can be severe complications associated with the extractions, including failure to heal, jaw fracture, and infection. I also accept that extractions can sometimes lead to changes in how my pet holds their tongue or lips. *

Initial

I accept that the veterinarians at Mayfair Animal Hospital are not board-certified dentists. Occasionally, there are circumstances that are undetectable before surgery that a board-certified dentist must address. I understand that it is in my pet's best interest for a referral if the veterinary team feels it necessary. *

Initial

Date *

Comment

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At Mayfair Animal Hospital, we take veterinary medicine to the next level without sacrificing the family feel vital to quality patient care. With our team of dedicated professionals, state-of-the-art facilities, and personalized services, we strive to provide exceptional veterinary care. Please request an appointment for your pet using our online system on PetDesk, and keep up with your pet’s health by downloading our app. We proudly serve the pets of Clio, Flint, Birch Run, Mt. Morris, and beyond.
We look forward to seeing you and your pet! Request an appointment by clicking the button below.

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Questions?

Get in touch! We look forward to hearing from you.

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Location

8025 N. Clio Rd.
Mt. Morris, MI 48458

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Contact Information

P: 810-785-0111
F: 810-787-6939
E: mah@mayfairvetflint.com

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Hours

Mon-Fri: 8 am – 5 pm
Sat-Sun: Closed

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Consent ForTreatment Form

Consent For Treatment Form

In-Patient Questionnaire

Consent For
Treatment Form