Highway 30 Veterinary Clinic

Surgery Consent Form

This form gives us your consent to give your pet everything he/she needs for safe treatment.

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Consent Submission Form

Owner's name *

First

Last

Email *

Phone Number *

Emergency phone number *

Patient's name *

Procedure date *

Name of procedure *

I am the owner/agent of the pet identified above. I am 18 years of age or older and I have authority to give this authorization. *

I authorize

I authorize the performance of the identified procedures and the use of associated anesthetics and other medications *

I authorize

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. The incident of complications from anesthesia is extremely low and we do not anticipate any in your pet but on rare occasions the following can occur 1. Allergic reaction to the anesthetic agents 2. Hear rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like humans, on very rare occasions, general anesthesia can result in death *

I have read and understand the risks

Surgical Risks Include: 1. Infection which may require additional testing and medication at an additional cost 2. Blood clots that can lodge in major organs causing stroke or rarely death 3. Bleeding which if severe may require additional hospitalization and further monitoring 4. Dehiscence of surgical site which may result in additional procedures and costs associated with correction *

I have read and understand the risks

The procedures identified above, the purpose for performing them, and the associated risks have been explained to my satisfaction. I realize that there can be no guarantee as to the pet’s condition or outcome of any procedure. *

I authorize

I also understand that unforeseen conditions may be revealed during the identified procedures, which in the opinion of the attending veterinarian may require more extensive or different procedures or treatments. I understand that reasonable efforts will be made to contact me to explain these procedures and obtain my instructions regarding them. However, if these efforts are unsuccessful. I authorize the performance of any procedures or treatments which are deemed necessary in the professional opinion of the attending veterinarian. *

I authorize

Date *

Signature *

Clear Signature

I have read and understand this authorization.

Highway 30 Veterinary Clinic

Surgery Consent Form

Consent Submission Form

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