Surgical Consent Form printable pdf download

Surgical Consent Form

Client Last Name: _____________________

First Name: __________________________________

Address: ___________________________________________________________________________

City: _________________________________ State: _________________ Zip: _________________

Home Phone: __________________________ Cell Phone: __________________________________

NUMBER WHERE I CAN BE REACHED AT ALL TIMES: _____________________________

Animal Name: _________________________ Cat: ______________

Dog: _____________

Sex: ____________ Breed: ______________

Color: ____________

Age: _____________

Does your pet have any health problems?

Yes

If yes, please describe: ________________________________________________________________

___________________________________________________________________________________

I would like pain medication for my dog or cat for an additional fee.

Yes

We are sorry but we do not accept checks or credit cards.

Payment must be made in CASH ONLY.

Consent for Surgical Sterilization

I, being of legal age and responsible for the animal described above, have the authority to grant Mobile Animal Surgical

Hospital and its staff members, volunteers, or agents my consent to receive, transport, prescribe for, treat and/or perform

sterilization surgery upon the animal named above.

I understand that modern techniques and trained staff will be used to care for all animals, and reasonable precautions will be

used against injury, escape or destruction of the animal. It is completely understood that Mobile Animal Surgical Hospital

and agents will not be held liable or responsible in any manner and I assume all risks..

If in the course of treatment a condition is discovered which requires medical attention or an additional procedure, such as

hernia repair or the administration of IV fluids, the attending veterinarian may, in his/her absolute discretion, perform such

procedures. I consent to these procedures and agree to pay reasonable additional charges, if any.

I understand that the animal will be given general anesthesia and that there is a risk associated with anesthesia. I further

understand that as long as, in the opinion of the attending veterinarian, the animal is an acceptable surgical candidate,

sterilization procedures will be performed regardless of the animal’s sex or medical condition (including pregnancy). I

understand that the attending veterinarian can refuse to perform any procedure on any animal for any reason. Such refusal is

at the sole discretion of the attending veterinarian.

I understand that the Mobile Surgical Animal Hospital does not offer 24 hour emergency service. If an emergency arises I

may need to seek the services of the nearest emergency clinic.

I also understand that all animals must be picked up from the clinic at the time designated by clinic staff on the same day as

surgery or I will be responsible for hospitalization and transport charges.

________________________________________

________________________________

Signature

Date

Surgical Consent Form