Elective Surgery Form

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Please complete the form in full.

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Preferred Clinic for Admission *

Clonakilty
Bandon

Pet Name *

Breed

Neutered

Weight

*In Kgs

Microchip No.

Sex

Age

Insurance Company

Patient ID

Owners Details

Full Name

First

Last

Email Address

Phone Number

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Please indicate preferred option for patient updates/discharge information

Consent Statement 1 *

I hereby give permission for the admission of the above name pet to Faxbridge Veterinary for Elective Surgery / Outpatient Procedure

I consent to the following EXTRA procedures while my pet is hospitalised:

Pre-Anaesthetic Blood test – (Recommended for all pets over 7yrs) €49.50
Full bloods - Comprehensive Biochemistry and Haematology €106.50
Microchip €35.00
Ear tip (cats)
Ear Clean €20.00
Nail Clip €20.00
Anal Gland expression (only if ongoing issue) €20.00
Overnight stay + food €38.50 - €45.00
Flea + Tick Treatment
Worm Treatment

Consent Statement 2 *

I understand that all sedation and anaesthetic procedures carry a risk, and that the staff at Faxbridge Veterinary will take all the necessary precautions to reduce those risks at all times.

Consent Statement 3 *

I agree to settle my entire account upon collection of my pet. I understand that Faxbridge Veterinary does not provide any credit unless arranged under special circumstances with the manager or treating vet.

Please my Statement

Consent Statement 4 *

I have received / would like to receive an estimate. I am aware that this is only an estimate and that extra costs may occur. I acknowledge that if extra costs occur that I will be contacted to approve any extra costs.

Consent for Photography and Social Media Use *

Yes, I give my consent
No, I do not give my consent

I give permission for Faxbridge Veterinary to take photographs and/or video recordings of my pet while under their care, and to use these images for promotional purposes, including but not limited to social media platforms.

Signature *

Clear Signature

Date *

Opening Hours

Clonakilty
Mon-Fri: 9am-6pm
Sat: 9am-1pm
T: 023 88 33252

Bandon
Mon-Fri: 9am-6pm
Sat: 9am-1pm
T: 023 88 41842

24/7 Emergency Services
T: 023 88 33252

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