Surgery Anesthesia Consent Form InstagramThis field is for validation purposes and should be left unchanged.Pet’s NameSpeciesCanineFelineSexMaleFemaleAgeChart#Owner’s Name First Last Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Emergency Contact/PhoneI request the following procedures today:Procedures: Select All 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) Select All 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/necessaryConsent 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 proceduresConsent 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 medicationConsent 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 MM slash DD slash YYYY