Countryside Vet
217-824-3051
Countryside Vet
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(217) 824-3051
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Mon-Fri 8 am to 5 pm*
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Large Animals: UNIVERSITY OF ILLINOIS URBANA-CHAMPAIGN
Appointment
Large Animals
Small Animals
Boarding
Grooming
Equine
Countryside Veterinary Service Anesthesia Consent Form
Date
Owner's Name:
Today's Phone #:
Patient Name:
Patient Weight:
Procedure
Please Check the Following:
Pre-anesthetic blood work highly recommended for the safety of your pet undergoing anesthetic procedure. While your pet may appear healthy, this testing can reveal hidden problems. Additional $95.00-$104.00.
Accept
Decline
Pain Medicine is important following any surgical procedure. Orai pain medication will be sent home with your pet as part of routine post-surgical care. Price varies depending on weight and procedure.
Accept
Decline
Post-Surgical laser treatment has proven to increase the rate of healing and decrease pain. Additional $15.00. Cat Declaws will receive two treatments for $30.00.
Accept
Decline
Pre-Operative anti-nausea injection helps prevent nausea post-op, last for 12 hours. Additional $22.00.
Accept
Decline
IV catheter and fluids are recommended to maintain your pet's blood pressure and decrease anesthetic risk, prevent dehydration, and to aid in recovery, as well as to provide a life-line in the event of an emergency. Additional $40
Accept
Decline
E-collar is recommended to stop patients from licking and chewing on incision sites. CVS will not be held liable for any damage done a patient that declines an E-collar. Additional $15.00.
Accept
Decline
Histopathology on mass removals is helpful in determining whether the mass is malignant or benign. Additional $137
Accept
Decline
**All surgery patients are given an antibiotic & pain injection after surgery $12.00**
*Any animal entering the clinic with fleas will be treated at the owner's expense*
Dogs
Rabies $17.00
DHLP $27.00
Bordetella $24.00
Heartworm Test $30.00
Fecal Float $22.00
Microchip $75.00
Flea Prevention
Heartworm Prevention
Deworm
Additional Services
Clean Teeth $130.00 $145.00
Nail Trim $20.00
Clean Ears $18.00
Express Anal Glands $15.00
Cats
Rabies $17.00
Feline Leukemia $25.00
FRVCP $25.00
Leukemia Test $38.00
Fecal Float $22.00
Microchip $75.00
Flea Prevention
Deworm
Clinic Policy: I understand that during the performance for this procedure, unforeseen conditions may he revealed that necessitate an extension or variance in the procedure(s). I expect Countryside Veterinary Service to use reasonable care and judgment in performing the procedure(s). The nature of the procedure and the risks involved has been explained to me, and I realize results cannot be guaranteed. I am also aware that unforeseen events resulting in the procedure(s) will not relieve me from any obligation to all reasonable costs incurred regarding the animal.
By checking this box, I represent that I am electronically signing these documents which will have the same effect as the execution of these documents by a written signature.
I Accept
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