Surgery Anesthesia Consent Form in Rogersville, TN

Comments

This field is for validation purposes and should be left unchanged.

Pet’s Name

Species

Sex

Age

Chart#

Owner’s Name

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Emergency Contact/Phone

I request the following procedures today:

Procedures:

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Spay
Neuter
Dental
X-Ray
Lab/Testing
Ultrasound
Other

Consent

I understand proof of vaccinations is required. If Rabies is not current, it will be given at owner’s expense.

My pet is current for the following: (must have documentation)

Select All
Canine Rabies
Distemper/Parvo
Kennel Cough/Bordetella
HW Prev
Feline Distemper
Feline Leukemia
Feline Rabies
Flea/Tick Control

I authorize (check all that apply)

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Examination and treatment/surgery
Pre-sedation blood work
IV fluids
Complimentary ear cleaning
Complimentary nail trim
Complimentary Laser
Necessary extractions
Microchipping

Consent

I am aware that the procedure may require an overnight stay. I am aware that monitoring overnight is by video cam and/or evening rounds of nurses and/or doctors. I understand that reasonable care will be used for the wellbeing of my pet and that the facility is secured by ADT security. I understand that the facility has no control over theft or natural disasters such as fire, earthquake, tornado.

Consent

Estimates are provided and I understand payment is due when services are rendered/upon discharge. Visit www.avma.org for information on veterinary liens. If I neglect to pick up my pet within 10 days, it will be considered abandoned and are hereby authorized to proceed as you deem best/necessary

Consent

I am the owner or the agent for the owner of the animal described above, and I have the authority to execute this consent.

Consent

I have also been informed that there are certain risks and complications associated with any operation or procedure of this type. They have been explained to me as well. I further understand that during the operations or procedures, unforeseen conditions may arise that may necessitate the performance of additional procedures

Consent

I authorize the use of appropriate anesthesia and pain relief medication as needed before or after the procedure. I have been informed that there are risks associated with the use of any medication

Consent

I understand that there may be adverse side effects to any medications or treatment and understand these reactions and/or side effects can negatively impact the health and well-being of my pet.

Consent

I understand the hospital support personnel will be used as deemed necessary by the veterinarian.

Signature

First Last

Date

Surgery Anesthesia Consent Form

Surgery Anesthesia Consent Form

I request the following procedures today:

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