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Surgery Consent Form

APPOINTMENT

Surgery Consent Form

Please complete this form in its entirety to allow our team to review your pet’s current health status.

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone *

Secondary Phone

Email *

Patient's Name *

Breed *

Sex *

Male
Neutered Male
Female
Spayed Female

Weight *

Anesthetic/surgical procedure(s) to be performed *

I am the owner (or authorized agent of the owner) of the animal described above and have the authority to execute this consent. I understand that some risk always exists with anesthesia, even in apparently healthy animals, including the possibility of death. I have discussed my concerns with the veterinarian. I realize that no guarantee, legal or ethical, can be made to me regarding the outcome of any procedure performed. I hereby authorize the use of anesthetics, as deemed necessary by the veterinarian. I understand that hospital personnel will be employed in treating my pet. I also understand that after surgery is completed for my pet, if I choose to leave my pet at the facility after business hours and/or overnight, there will not be any hospital team members on site to care for my pet in the event of an emergency. I have carefully read, and fully understand this consent. The fees associated with these services have been explained to me, and I agree to pay such fees in full at the time my pet is released from the hospital. *

I have read and agree

I understand that the attending veterinarian will make every effort to contact me regarding treatment in the case of unforeseen emergencies. If unable to contact me, the staff may or may not have my permission to proceed with life-sustaining procedures, including CPR. I understand that there will be additional charges if CPR is performed on my pet. *

I have read and agree

CPR Consent *

I give permission for CPR
I do not give permission for CPR

Signature *

Today's Date *

Surgery Consent Form

Surgery Consent Form

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