Surgery / Anesthesia Consent Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet’s before your visit.

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Surgery / Anesthesia Consent Form

If you have any questions, please feel free to email us at contact@hartanimalclinic.com.

This form may be printed off as a pdf and brought in at our appointment or filled out in the space below and automatically sent to our clinic.

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Client Name *

First

Last

Patient Name *

Email *

Phone number at which owner can be reached today or tomorrow: *

Additional Number

Anesthetic and surgical procedure's to be performed: *

Pre-anethetic bloodwork: Our greatest concern is the wellbeing of your pet. We will perform a physical examination before administering anesthesia. However, disorders of the liver, kidneys, or blood, are not detected unless blood testing is done. Abnormalities of any of these may increase anesthetic risk. Also establishing baseline levels for your pet is important as they age. For these reasons we highly recommend pre-anesthetic blood screens.

I agree
I decline

I, the undersigned owner or agent of the pet identified above, authorize the staff of Hart Animal Clinic to perform the above procedure's. *

I have read and agree

Additional services that you would like performed while your pet is staying with us. *

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

Would you like your pet’s vaccines and / or heartworm test updated?

When was the last time fed?

Any other concerns/allergies/procedures?

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 procedure's is/are initiated. *

I have read and agree

I am over 18 and 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. *

I give my permission [yes]
I do not give my permission [no]

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow up radiographs, re-check physical exams and additional surgery due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions. I have been provided an estimated cost for the procedure's listed above. I assume financial responsibility for the recommended services and will provide payment in full at the time my pet is discharged from the hospital. I have read and fully understand the terms and conditions set forth above. *

I have read and agree

Signature *

Clear Signature

Date *

Surgery / Anesthesia Consent Form

Surgery / Anesthesia Consent Form

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