Fillable Surgery Consent Form printable pdf download

Date ______________________

SURGERY CONSENT FORM

This form is available to download on our website

I, _________________________, am at least 18 years of age and I am the legal owner of the animal described in this medical

record. I am admitting my pet (name) ______________________ for surgery to be performed by one of the Veterinarians at

Elliott Bay Animal Hospital on (date) ______________________.

Phone numbers: (1st) _______________________________________ (2nd) _____________________________________

E-mail (optional) _____________________________________________________________________________________

In the event your pet will need to stay overnight, what do you feed your pet and how much?

________________________________________________________________________________________________

In the event I cannot be reached at the numbers above I request:

The doctors/staff continue with all appropriate medical care as needed.

Discontinue medical care until I can be reached.

Surgical procedure being done:

______________________________________________________________

Location (if appropriate): Right

Left

Front

Back

Side

Does your pet have a microchip?…………….………………………………………………………. YES

Has your pet eaten this morning? ……………………………………………………………………. YES

Has your pet had morning medications (list if any) ………… YES

_____________________________________________________________

Does your pet need a prescription refill today?.…

Yes

Please specify ______________________________

My signature below verifies the following:

A) The diagnosis, medical/surgical care and post surgical care has been described to my satisfaction.

B) A financial estimate has been prepared for me. I understand these expected costs are only estimates and

that situations can arise that would alter the actual medical cost.

C) I accept that all medical/surgical procedures involve some risk. I understand that these risks include but

are not limited to:

1) General anesthesia. I realize that some patients may have adverse reactions to anesthesia that may result in

permanent injury or death.

2) Infections can complicate wound healing. I realize that despite all precautions, a small percentage of patients may

develop infections. I understand that these patients require additional medical care, which is not covered in my

medical estimate.

3) Unexpected outcomes. I understand that no promises or warranties can be given. I realize that complications can

occur at any point during the procedure or the healing process. I accept that some complications can prevent my pet

from achieving the outcome I had hoped for.

SIGNATURE ________________________________________________

**Please discuss the below options with the doctor during the surgical admit appointment**

My pet’s post surgical care has been discussed with me to my satisfaction and I have chosen:

(check, date and sign with your choice).

Transfer of my pet to an overnight care facility. I accept any risk associated with the transport of my pet. I realize

this is an additional cost of care.

SIGNATURE ________________________________________________ Date ____________________

Overnight hospitalization will be provided by Elliott Bay Animal Hospital. I understand that my pet will be

unattended for a portion of their time, and I accept the risk associated with my pet’s hospitalization.

SIGNATURE ________________________________________________ Date ____________________

I request my pet to be discharged to my care the day of surgery. I accept full responsibility for my pet’s care

once discharged to me by Elliott Bay Animal Hospital.

SIGNATURE ________________________________________________ Date ____________________

Surgery Consent Form

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