Name: Central Veterinary Services
Address: 8092 Perimeter Hwy, Oak Bluff, MB, R0G 1N0, Canada
Telephone: 204-275-2038
Price range: $

Today's Date *

Owner's Name *

First

Last

Email address on account *

**Your email address is strictly used for internal purposes and for communication directly with you. We send out your pet’s appointment notes/reminders, revised policies, internal promotions that would apply to you, inclement weather updates, estimates for surgical/medical services as well as surveys on how to improve our services.

Pet's Name *

Phone number at which you can be reached during the procedure? *

Additional number that you can be reached at?

Procedure to be performed *

If Other, please specify procedure: *

Important Information about your pet’s dental procedure: Our dental procedure process has been carefully considered for the safety of your pet, and the amount of time your pet will spend under anesthetic will not exceed a safe acceptable limit. This means that at times, when the work needing to be done is significant, the dental procedures will be staged. A separate second procedure spaced 4 to 8 weeks later, may be required to accomplish the work needing to be done. Rest assured, by splitting the full procedure, the total cost to you will not be more than if performed in one event. Fortunately, it will be safer for your pet and allow us to better tailor treatment as needed. If you would like more information about your pet’s dental health journey, please visit the Dental Health Decision Tree under Dentistry Services.

Important Information about your pet’s dental procedure: Our dental procedure process has been carefully considered for the safety of your pet, and the amount of time your pet will spend under anesthetic will not exceed a safe acceptable limit. This means that at times, when the work needing to be done is significant, the dental procedures will be staged. A separate second procedure spaced 4 to 8 weeks later, may be required to accomplish the work needing to be done. Rest assured, by splitting the full procedure, the total cost to you will not be more than if performed in one event. Fortunately, it will be safer for your pet and allow us to better tailor treatment as needed. If you would like more information about your pet’s dental health journey, please visit the Dental Health Decision Tree under Dental Services.

Please acknowledge that you understand and agree to the dental disclaimer. *

I understand and agree.

Would you like to add a complimentary nail trim to your pet's procedure? *

Yes
No

Have you received an estimate for this procedure within the last 30 days? *

Yes
No

Please refer to your pet’s estimate for prices for the below options.

Pre-Anesthetic Bloodwork: Bloodwork is recommended prior to every anesthetic procedure to ensure that your pet is fully able to handle the anesthetic for a lengthy procedure. We take a small amount of blood prior to any sedation and run it through a number of machines to check many internal values that we are unable to see with our naked eye. This may give us the ability to catch something before it gets advanced and clinical. This test checks their red blood cells, white blood cells, platelets, liver enzymes, kidney enzymes, electrolytes, and many more things. If this test comes back all normal, this will give us a good baseline as your pet ages. At this point this is optional, but the test is highly suggested for every pet!

Would you like to have Pre-Anesthetic Bloodwork completed prior to your pet’s procedure? *

Yes
No

Pre-Anesthetic Bloodwork: Bloodwork is recommended prior to every anesthetic procedure to ensure that your pet is fully able to handle the anesthetic for a lengthy procedure. We take a small amount of blood prior to any sedation and run it through a number of machines to check many internal values that we are unable to see with our naked eye. This may give us the ability to catch something before it gets advanced and clinical. This test checks their red blood cells, white blood cells, platelets, liver enzymes, kidney enzymes, electrolytes, and many more things. If this test comes back all normal, this will give us a good baseline as your pet ages.

Have you already performed the mandatory pre-anesthetic bloodwork for your pet’s TPLO? * *

Yes
No

Spay Procedure: This is a bundled cost that includes your pet’s hospitalization for the day, pain medications before and after the procedure, anesthesia during the procedure, surgical supplies, and the removal of their reproductive organs to prevent future pregnancy and heat cycles.

Is there a chance your pet could be pregnant? *

Yes
No
Unsure

If my pet is found to be pregnant at the time of spay, I understand that during this surgical procedure the pregnancy will be terminated and there will be an additional Pregnancy Fee incurred. *

Yes
No

Neuter Procedure: This is a bundled cost that included your pet’s hospitalization for the day, pain medications before and after the procedure, anesthesia during the procedure, surgical supplies, and the removal of their reproductive organs to prevent roaming, aggression, urine marking and more.

Subcutaneous Fluids: This is optional during your pet’s neuter procedure but is highly recommended for all animals undergoing anesthesia. Subcutaneous Fluid Therapy will help to maintain your pet’s blood pressure during surgery and will help them recover quicker from anesthesia.

Intravenous Fluid Therapy: This is optional during your pet’s neuter procedure but is highly recommended for all animals undergoing anesthesia. Intravenous Fluid Therapy will help to maintain your pet’s blood pressure during surgery and will help them recover quicker from anesthesia. Note this will result in your pet having a shaved spot on their front arm and will provide vein access for the duration of their procedure.

Intravenous Fluid Therapy: Intravenous Fluid Therapy will help to maintain your pet’s blood pressure during surgery and will help them recover quicker from anesthesia. Note this will result in your pet having a shaved spot on their front arm and will provide vein access for the duration of their procedure.

Would you like to have Intravenous Fluid Therapy included in your pet’s procedure? *

Yes
No

Would you like to have Subcutaneous Fluids included in your pet’s procedure? *

Yes
No

Intravenous Fluid Therapy: This is included with your pet’s spay procedure. Intravenous Fluid Therapy will help to maintain your pet’s blood pressure during surgery and will help them recover quicker from anesthesia. Note this will result in your pet having a shaved spot on their front arm and will provide vein access for the duration of their procedure.

Forms of Identification:

Tattoo: This is a series of numbers and letters that gets placed in your pet’s right ear that are linked with the Winnipeg Humane Society. Please note that a tattoo does have the ability to fade over time. Tattoos are also only registered within Manitoba, therefore if you travel or move this may not be the best option.

Would you like your pet to receive a Tattoo? *

Yes
No

Microchip: This is a small microchip that is implanted under your pet’s skin during their procedure. This means if they are ever lost and are taken to a local rescue, shelter, humane society, vet clinic, etc they can use a special scanner to read her microchip number which can be searched on a North America wide database online.

Would you like your pet to receive a Microchip? *

Yes
No
Already has one

Would you like to add a complimentary nail trim to your pet's procedure? *

Yes
No

Elizabethan Collar (Aka. Cone): This is a standard plastic cone that will prevent your pet from licking at their surgical incision. We also offer Buster Foam Collars for an additional cost if you wish to purchase one. Buster Foam Collars are similar in shape to the plastic cones, however they are made of foam. We offer this option as some pets do not tolerate the plastic cones and can damage walls, furniture, etc. with them.

Do you want an alternative to the plastic e-collars that is best suited for your pet? * *

Yes
No

Therapeutic Laser: On the high end of your estimate we have included an optional therapeutic laser treatment, this is where one of our trained RVT's will apply a laser treatment to your pet’s surgical site after they are recovered from surgery. Laser works by increasing the blood circulation to the area to reduce post-surgical swelling, inflammation, discomfort and promotes quicker healing of their surgical incision.

Would you like your pet to receive a therapeutic laser treatment after their surgery? *

Yes
No

Metacam: This is a mandatory medication that is sent home to help with any post-operative inflammation. This will generally be given for 3-5 days post-op.

Tibial Plateau Leveling Osteotomy (TPLO) Procedure (Surgery & Anesthetic Time along with Surgical Supplies): As noted on your pet’s estimate this is a range, as it is difficult to estimate the exact amount of time it will take the attending veterinarian to perform this procedure until they are in surgery. As a clinic policy we always honour the high end of the estimate you were given (estimates valid for 30 days). This means if it takes us longer than expected, we discount the total to only as high as the high end of your pet’s valid estimate. And if the TPLO goes quicker than you only get charged for the time it took. This cost also covers the surgical supplies required.

Have you given your pet any medications or supplements in the past week? *

Yes
No

Please list any and all medications your pet has received. *

Do you want an alternative to the plastic e-collars that is best suited for your pet? *

Yes
No

Have you noticed any signs of heat from your pet? (ie. swollen vulva, bloody or straw coloured discharge from the vulva, excessive licking of the genital area, agitated/nervous/aggressive behaviour or urinating more frequently) *

Yes
No

Have you given your pet any medications or supplements in the past week? *

Yes
No

I am not to feed my pet after 8pm and I am to remove my pet’s water after 10pm the night before the procedure. *

I have read and agree.

Any other concerns/allergies/procedures?

Is it estimated your dog will be over 80 lbs at their adult weight? *

Yes
No

Would you like to have an elective gastropexy (stomach tacking) performed at the same time as their spay/neuter?

Yes
No

I do hereby give the veterinarians of Central Veterinary Services, and such assistants as may be selected by them, complete authority to perform the above procedure(s), which I understand, or which have been explained to me. If you have not been informed regarding the above procedures to your satisfaction or do not understand, it is your responsibility to inquire at the time of signing this document.

I understand that unforeseen conditions may be revealed during the identified procedure(s) which, in the opinion of the attending veterinarian, may require more extensive or different procedures or treatments. I understand that reasonable efforts will be made to contact me to explain these procedures and treatments and obtain instructions regarding them. However, if the efforts are unsuccessful, I authorize performance of any life sustaining procedures or treatments, which are in the professional opinion of the attending veterinarian. *

Yes, I give my permission.
No, I do not give my permission.

I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedures or treatments are initiated. *

I have read and agree.

Privacy of personal information is an important principle to Central Veterinary Services. In compliance with the federal Personal Information Protection and Electronic Documents Act (PIPEDA), we are committed to collecting, using, and disclosing personal information responsibly and only to the extent necessary for the goods and services we provide. The primary purpose for collecting personal information is to provide veterinary services.

Please refer to your pet’s estimate for prices for the below options.

Pre-Anesthetic Bloodwork: Bloodwork is recommended prior to every anesthetic procedure to ensure that your pet is fully able to handle the anesthetic for a lengthy procedure. We take a small amount of blood prior to any sedation and run it through a number of machines to check many internal values that we are unable to see with our naked eye. This may give us the ability to catch something before it gets advanced and clinical. This test checks their red blood cells, white blood cells, platelets, liver enzymes, kidney enzymes, electrolytes, and many more things. If this test comes back all normal, this will give us a good baseline as your pet ages. At this point this is optional, but the test is highly suggested for every pet!

Would you like to have Pre-Anesthetic Bloodwork completed prior to your pet’s procedure? *

Yes
No

Extractions: *

Have the doctor continue with removing the teeth that are deemed necessary for extraction.
Call with an estimate prior to proceeding with the extractions.
Extractions declined at this time. Please re-schedule extractions for a later date, which would entail extra charges.

Intravenous Fluid Therapy: This is included with your pet’s dental procedure. Intravenous Fluid Therapy will help to maintain your pet’s blood pressure during surgery and will help them recover quicker from anesthesia. Note this will result in your pet having a shaved spot on their front arm and will provide vein access for the duration of their procedure.

Dental Prophylaxis (Clean, Scale & Polish): This is a bundled cost that includes many things! It will include your pet’s hospitalization for the day, Intravenous Fluid Therapy before, during, and after their procedure. Also included in this bundle are full mouth dental radiographs (x-rays) for your pet which are reviewed by the attending veterinarian who then evaluates the areas above and below the gumline to ensure each tooth is as healthy as possible. Dental radiographs provide us more insight as to whether a tooth should be extracted, or other treatment is recommended. The Registered Veterinary Technologist (RVT) will then clean all of your pet’s teeth. Each tooth will be scaled and polished to keep them as clean as possible for as long as possible!

Dental Extractions: As noted on your pet’s estimate this is a range, as it is difficult to estimate the exact amount of time it will take to remove the diseased teeth. As a clinic policy, we always honour the high end of the estimate you were given (estimates valid for 30 days). This means if it takes us longer than expected, we discount the total to only as high as the high end of your pet’s valid estimate. And if the extraction(s) goes quicker then you only get charged for the amount of time it took. This cost also covers the surgical supplies required.* (Please remove and extract all diseased teeth at the attending veterinarian’s discretion (charges for extractions will be incurred) or Please contact me prior to completing any advanced dental work on my pet including any extractions or removal of diseased teeth)

Dental Nerve Block(s): This is a medication given in the surrounding area where a tooth is being extracted if required. This medication’s effect will last for about 4 hours and will assist with your pet’s post-operative pain management.

Medications:

Post-operative medications vary greatly for each pet’s dental procedure; therefore, a cost has not been provided on your pet’s estimate. These may include antibiotics and/or anti-inflammatories. *

I understand that additional fees may be incurred if it is recommended that my pet receive post-operative medications.

Have you given your pet any medications or supplements in the past week? *

Yes
No

Please list any and all medications your pet has received. *

Have you received an estimate for this procedure within the last 30 days? *

Yes
No

Are there any changes that would affect this estimate? *

Yes
No

Please specify below or contact the clinic at 204-275-2038 / info@centralvet.ca to update your estimate to ensure it is as accurate as possible. *

After completing this form, please send us an email or text update on how the needed services have changed.

After completing this form, please send us an email or text to alert us so we can provide you an estimate to review.

I am not to feed my pet after 8pm and I am to remove my pet’s water after 10pm the night before the procedure. *

I have read and agree.

Any other concerns/allergies/procedures?

If your pet is eligible or soon due for their annual exam, would you like to have this performed by the Veterinarian on the day of the surgery? *

Yes
No

Would you like to update any vaccines that are due? Please specify which vaccine(s):

DA2PP (Distemper Combo)
Rabies
Lyme
Bordetella (Kennel Cough)

Would you like to update any vaccines that are due? Please specify which vaccine(s):

FRCP (Distemper Combo)
Rabies
Feline Leukemia

I do hereby give the veterinarians of Central Veterinary Services, and such assistants as may be selected by them, complete authority to perform the above procedure(s), which I understand, or which have been explained to me. If you have not been informed regarding the above procedures to your satisfaction or do not understand, it is your responsibility to inquire at the time of signing this document.

I understand that unforeseen conditions may be revealed during the identified procedure(s) which, in the opinion of the attending veterinarian, may require more extensive or different procedures or treatments. I understand that reasonable efforts will be made to contact me to explain these procedures and treatments and obtain instructions regarding them. However, if the efforts are unsuccessful, I authorize performance of any life sustaining procedures or treatments, which are in the professional opinion of the attending veterinarian. *

Yes, I give my permission.
No, I do not give my permission.

I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedures or treatments are initiated. *

I have read and agree.

Privacy of personal information is an important principle to Central Veterinary Services. In compliance with the federal Personal Information Protection and Electronic Documents Act (PIPEDA), we are committed to collecting, using, and disclosing personal information responsibly and only to the extent necessary for the goods and services we provide. The primary purpose for collecting personal information is to provide veterinary services.

Please refer to your pet’s estimate for prices for the below options.

Pre-Anesthetic Bloodwork: Bloodwork is recommended prior to every anesthetic procedure to ensure that your pet is fully able to handle the anesthetic for a lengthy procedure. We take a small amount of blood prior to any sedation and run it through a number of machines to check many internal values that we are unable to see with our naked eye. This may give us the ability to catch something before it gets advanced and clinical. This test checks their red blood cells, white blood cells, platelets, liver enzymes, kidney enzymes, electrolytes, and many more things. If this test comes back all normal, this will give us a good baseline as your pet ages. At this point this is optional, but the test is highly suggested for every pet!

Would you like to have Pre-Anesthetic Bloodwork completed prior to your pet’s procedure? *

Yes
No

Intravenous Fluid Therapy: This may or may not have been included in your pet’s estimate, and a team member will discuss this procedure if optional with you the morning of your pet’s procedure to ensure the best recommendation is made. Intravenous Fluid Therapy will help to maintain your pet’s blood pressure during surgery and will help them recover quicker from anesthesia. Note this will result in your pet having a shaved spot on their front arm and will provide vein access for the duration of their procedure.

Lump Removal Procedure (Surgery & Anesthetic Time along with Surgery Pack): As noted on your pet’s estimate this is a range, as it is difficult to estimate the exact amount of time it will take the attending veterinarian to remove the lump until they are in surgery. As a clinic policy, we always honour the high end of the estimate you were given (estimates valid for 30 days). This means if it takes us longer than expected, we discount the total to only as high as the high end of your pet’s valid estimate. And if the lump removal(s) goes quicker then you only get charged for the amount of time it took. This cost also covers the surgical supplies required.

Enucleation Procedure (Surgery & Anesthetic Time along with Surgery Pack): As noted on your pet’s estimate this is a range, as it is difficult to estimate the exact amount of time it will take the attending veterinarian to remove the eye(s) until they are in surgery. As a clinic policy we always honour the high end of the estimate you were given (estimates valid for 30 days). This means if it takes us longer than expected, we discount the total to only as high as the high end of your pet’s valid estimate. And if the enucleation goes quicker than you only get charged for the amount of time it took. This cost also covers the surgical supplies required.

Cherry Eye Repair Procedure (Surgery & Anesthetic Time along with Surgery Pack): As noted on your pet’s estimate this is a range, as it is difficult to estimate the exact amount of time it will take the attending veterinarian to repair the cherry eye(s) until they are in surgery. As a clinic policy, we always honour the high end of the estimate you were given (estimates valid for 30 days). This means if it takes us longer than expected, we discount the total to only as high as the high end of your pet’s valid estimate. And if the cherry eye repair(s) goes quicker then you only get charged for the amount of time it took. This cost also covers the surgical supplies required.

Cystotomy Procedure (Surgery & Anesthetic Time along with Surgery Pack): As noted on your pet’s estimate this is a range, as it is difficult to estimate the exact amount of time it will take the attending veterinarian to remove the stones from your pet’s bladder until they are in surgery. As a clinic policy, we always honour the high end of the estimate you were given (estimates valid for 30 days). This means if it takes us longer than expected, we discount the total to only as high as the high end of your pet’s valid estimate. And if the cystotomy goes quicker then you only get charged for the amount of time it took.

Histopathology: This is where we send the lump(s) away to a pathologist to tell us the exact origin of the mass, if we got full margins, and what we can expect due to the nature of the lump.

Would you like your pet’s lump(s) sent away for Histopathology? *

Yes
No

Medications:

Post-operative medications vary greatly for each pet’s procedure; therefore, a cost has not been provided on your pet’s estimate. These may include antibiotics and/or anti-inflammatories. *

I understand that additional fees may be incurred if it is recommended that my pet receive post-operative medications.

Please complete the following questions so that we can submit your pet’s urolith sample for analysis to the University of Guelph (no additional charges will be incurred for analysis):

Environment of pet? *

Outdoor
Indoor
Both

Have you boarded this pet in the last 3 months? *

Yes
No

Number of other animals on the premises: *

Please also indicate species of animal(s), if applicable.

What diet was your pet fed prior to urolith diagnosis? *

How long has this diet been fed? *

What percentage of your pet’s diet is wet and what percentage of your pet’s diet is dry? *

Are you feeding this diet in meals or free feeding? *

Meals
Free feeding

How many meals per day? *

Were treats fed? *

Yes
No

Were table foods fed? *

Yes
No

When your pet was diagnosed with bladder stones were they receiving steroids or vitamin C? *

Yes
No

Have you given your pet any medications or supplements in the past week? *

Yes
No

Please list any and all medications your pet has received. *

I am not to feed my pet after 8pm and I am to remove my pet’s water after 10pm the night before the procedure. *

I have read and agree.

Any other concerns/allergies/procedures?

What other procedures would you like performed on your pet during your appointment?

Are there any medications/supplements you wish to pick up?

Would you like to pick up your pet’s tick and heartworm prevention at your pet’s appointment?

Yes
No

In our area, tick/flea prevention is recommended from April to November or when temperatures are above 0°C, which can occur beginning in March.

Heartworm prevention is recommended from June 1st to the end of November when temperatures reach averages of 10°C.

Optional: Specify which product(s) and how much of each.

Would you like a 4DX Test completed at your pet’s appointment today?

Yes
No
I would like to learn more about this test before deciding

A 4DX Test is a powerful screening tool used to evaluate the health of your dog in preparation for Heartworm and tick season. In ten minutes and with only four drops of blood, this test detects exposure to diseases transmitted by mosquitos and ticks including Heartworm (mosquitoes), Lyme, Anaplasma and Ehrlichia (ticks). All four diseases are prevalent in Manitoba.

I do hereby give the veterinarians of Central Veterinary Services, and such assistants as may be selected by them, complete authority to perform the above procedure(s), which I understand, or which have been explained to me. If you have not been informed regarding the above procedures to your satisfaction or do not understand, it is your responsibility to inquire at the time of signing this document.

I understand that unforeseen conditions may be revealed during the identified procedure(s) which, in the opinion of the attending veterinarian, may require more extensive or different procedures or treatments. I understand that reasonable efforts will be made to contact me to explain these procedures and treatments and obtain instructions regarding them. However, if the efforts are unsuccessful, I authorize performance of any life sustaining procedures or treatments, which are in the professional opinion of the attending veterinarian. *

Yes, I give my permission.
No, I do not give my permission.

I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedures or treatments are initiated. *

I have read and agree.

Privacy of personal information is an important principle to Central Veterinary Services. In compliance with the federal Personal Information Protection and Electronic Documents Act (PIPEDA), we are committed to collecting, using, and disclosing personal information responsibly and only to the extent necessary for the goods and services we provide. The primary purpose for collecting personal information is to provide veterinary services.

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Date *

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