Dehart Veterinary Services
Call or Text: (903) 590-7722 or (903) 312-6422
Email: dehartveterinaryservices@yahoo.com
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Surgery Check-In Form

  • Pet(s)



  • PLEASE ANSWER THE FOLLOWING QUESTIONS

  • WOULD YOU LIKE US TO DO THE FOLLOWING:

    If your pet has fleas/ticks a 30 day product will be applied for $10. This is for sanitation and protection of the other animals.
  • PLEASE INDICATE BELOW WHICH SERVICES YOU WOULD LIKE US TO PERFORM TODAY:

    • Dehart Veterinary Services, PLLC. uses qualified staffing & approved materials for all procedures performed. It is important for you to understand that the risk of injury or death, although extremely low, is always present, just as it is for humans who undergo surgery. Carefully read, & ensure you understand, the following before signing your name:
      • I, acting as owner or agent of the pet named above, hereby request and authorize Dehart Veterinary Services, PLLC., through whomever veterinarians they may designate, to perform an operation for sexual sterilization of the animal named on the above portion of this form.
      • I understand that the operation I have elected presents some hazards, and that injury to, or death of, an animal may conceivably result, for there is some risk in the procedure, and some risk in the use of anesthetics and drugs provided for the procedure.
      • I understand that it takes up to 2 weeks for vaccinations to protect my animal and therefore my animal is not sufficiently vaccinated against potentially communicable diseases if not vaccinated 2 weeks prior to surgery. I understand that if my pet develops kennel cough/upper respiratory infection after surgery, I am responsible for treatment at my own cost.
      • I certify that my animal is in good health and, if an adult, has had no food since 12:00 midnight the evening prior to surgery.
      • I understand that Dehart Veterinary Services, PLLC. has the right to refuse service to any animal to whom surgery is deemed a health risk.
      • I understand that Dehart Veterinary Services, PLLC. may not perform a complete physical examination before surgery is performed, and that my animal will not receive pre-operative bloodwork unless I have opted for this service.
      • I understand that some factors significantly increase surgical risk, including, but not limited to, increased age, pregnancy, estrus/heat, obesity, and diseases such as feline immunodeficiency virus (FIV), feline leukemia (FeLV), and heartworms.
      • I understand that if my animal is pregnant, the pregnancy will be terminated at surgery without notification.
      • I understand that if my animal is pregnant, in heat, or is cryptorchid the veterinarian will proceed with the surgery at an extra charge.
      • I understand that if my animal requires a longer surgery time there will be an extra charge.
      • If my pet has fleas, a short acting flea treatment will be administered at my expense at the cost of $10.
      • I understand that if I do not retrieve my pet(s) at the agreed-upon time and I cannot be contacted, Dehart Veterinary Services, PLLC. will exercise its right to turn the animal over to the local Animal Control agency. If I am unable to get my pet(s) at the designated pick up time it is my responsibility to contact Dehart Veterinary Services to make arrangements. If I cannot come get my pet(s) and the pet(s) have to remain overnight a boarding fee of no less than $40 per night will be charged. If the pet(s) are not picked up in 24 hours they will be turned over to the local Animal Control Agency. It is my responsibility to make arrangements to pick up by pet(s) by the designated pick up time. A late fee ($20) will be assessed 30 minutes after the designated pick up time.
      • I hereby release Dehart Veterinary Services, PLLC., all veterinarians, assistants, volunteers, directors, and employees from any and all claims arising out of, or connected with, the performance of this procedure or any adverse reactions from vaccinations. I agree that I have not and will not claim any right of compensation from them, or any of them, or file action by reason of such sterilization or attempted sterilization of such animal or any consequences related thereto.
      • I hereby agree to indemnify and hold Dehart Veterinary Services, PPLC. harmless for any damages caused by any unforeseeable events including fire, vandalism, burglary, extreme weather, natural disasters, or acts of God.
      • I hereby agree to listen, read, and follow the discharge instructions that are given to me when I pick up my pet(s). I acknowledge that any injury/infection caused by failure to adhere to the discharge instructions will need to be treated at my own expense. I agree to first contact Dehart Veterinary Services, PLLC and attempt to have them recheck my pet(s) prior to bringing them to my regular veterinarian for a recheck. If Dehart Veterinary Services, PLLC cannot be reached prior to my pet(s) recheck I will contact them afterward to given them an update on his/her condition.
      • I understand that Dehart Veterinary Services is NOT responsible for broken carriers.
      • I understand that IF my dog is current on its rabies vaccination and I DID NOT show the certificate at check in then I am REQUIRED to get proof of the rabies vaccine BEFORE NOON. If I fail to do this I understand that a rabies vaccine will be given to my pet at an extra charge of $12.
    • YOUR ANIMAL WILL RECEIVE A SMALL GREEN TATTOO ON HIS/HER UNDERSIDE TO SHOW THAT HE/SHE HAS BEEN STERILIZED. BY SUBMITTING THIS FORM YOU ARE AGREEING AND FULLY UNDERSTAND EVERYTHING STATED ABOVE, INCLUDING EXTRA CHARGES.


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