Pico Veterinary Hospital

Pre-Surgical Consent Form

Fill out our Pre-Surgical Consent Form below! Use the button to get started.

Pico Veterinary Hospital of Yorba Linda Pre-Surgical Consent Form

It is our mission to partner with our clients to nurture and preserve the human-animal bond by providing compassionate, expert, and affordable veterinary care from your pet’s first adventure throughout a long and healthy life. Please fill out the form below as accurately as possible.

Name *

First

Last

Phone

Email *

Pet's Name *

1. Emergency Contact Name *

Phone

2. Emergency Contact Name *

Phone

Procedure to be performed:

Food/ Medications:

Last time they ate:

Date

Time

Any known allergies:

All items below are in ADDITION to the base price for surgery. Please indicate which additional procedures you would like done today.

Pre-Operative Blood Screening: This screening helps us identify potential problems while the patient is undergoing surgery. The more current the screening, the safer the patient is under anesthesia. ($185.00)
IV Catheter & Fluids: The catheter allows direct access to the vein in case of an emergency, while the fluids maintain essential blood flow to vital organs and optimal blood pressure. ($65.00)
Tooth Extractions: Teeth that need to be removed can lead to serious and costly medical problems, excruciating pain and even death. The best time for extractions is while the patient is already under anesthesia.

All items below are in ADDITION to the base price for surgery. Please indicate which additional vaccinations you would like done today.

Canine Rabies ($25)
DHPP ($25)
Bordetella ($25)
Influenza ($44)
Leptospirosis ($28)
Feline Rabies ($25)
FVRCP ($25)

All items below are in ADDITION to the base price for surgery. Please indicate which additional services you would like done today.

Nail Trim ($25)
Anal Glands( $32)
Ear Cleaning ($35)
Deworming ($15)
Heartworm Test ($45)
Homeagain Microchip ($75)

Please note that a non- optional, additional charge will be applied for female patients in heat undergoing a spay procedure($75 and up), and male patients with undescended testicles undergoing a neuter. ($110 - $300)

I understand

I do hereby certify that I am the owner or authorized agent for the animal named above. I do hereby give Pico Veterinary Hospital, their agents, employees and representatives full and complete authority to perform the medical/surgical procedure and associated anesthesia for the procedure(s) stated above. I agree to pay in full for services rendered, including those deemed necessary for medical or surgical complications or otherwise unforeseen circumstances. *

Signature

Date / Time *

Comment

Ready For A Visit?

We Look Forward to Seeing You Soon!

Pico Veterinary Hospital of Yorba Linda proudly delivers lifelong care for your pets in Yorba Linda, Placentia, Villa Park, Anaheim Hills, Olive, Orange Park Acres, Brea, and beyond.

Questions?

Get in touch! Complete our online form, and a member of our team will be in touch with you shortly.

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Location

23661 La Palma Ave
Yorba Linda, CA 92887

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Contact Information

P: 714-503-8928
F: 714-692-1820
E: [email protected]

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Hours

Mon-Fri: 8am – 6pm
Sat: 8am – 3pm
Sun: Closed

Name *

First

Last

Email *

Phone

How can we help you? *

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