Medical/surgical Consent Form
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1Medical/Surgical Consent Form
Date: ____________________
Client Name: ________________________________________
Address:
________________________________________
________________________________________
Phone:
________________________________________
E-mail: ________________________________________
Patient Name: ________________________ _
Sex: ______________
Species:
_________________________
Color: _______________________
Breed:
_________________________
Age/DOB: ____________________
Medical Procedure(s): _____________________________________________________
If requested, we would be glad to provide an estimated cost. This is only an estimate. Some procedures may
require more services than originally anticipated. Please ask for an estimate at time of check-in or request a phone
call from the Dr. prior to starting the procedure.
Contact Information: It is imperative that we have phone numbers where you can be reached
immediately.
Phone number: __________________________ Home Work Cell - Please circule
__________________________ Home Work Cell
If you can not be reached immediately when a decision must be made for the care of your pet,
do you wish us to:
______
Proceed with the care of your pet at the discretion of the attending Dr.
______
Do not proceed without speaking to you first. You understand that this may
mean not performing or completing a procedure until you can be reached, and
May cause your pet prolonged or additional anesthesia.
Has your pet eaten today? ____________
If yes, what time? _____________________
Are there any special conditions we should be aware of? _________
If yes, please describe: ______________________________________________________
Please indicate if you would also like any of the following services:
Nail trim: _________________________
Microchip: ____________________________
Anal gland expression: ______________
Fecal testing: __________________________
Microchip: ________________________
Vaccinations: __________________________
I authorize Family Pet Veterinary Practice to administer medical/surgical treatment as necessary. I also consent to
the administration of such anesthetics as necessary. I certify that I have read and fully understand the above
authorization for medical/surgical treatment. I understand the advantages and potential risks. I also certify that
no guarantee or assurance has been made as to the results that may be obtained. Further, I understand that all
fees are due in full when services are complete and I agree to pay those fees. I also understand that I am
responsible for all finance, collections, and attorney fees incurred if I do not pay these charges.
Signature of Owner or Authorized Agent: ____________________________________________
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