Please Note: We will be closing early at 1 PM on Tuesday, December 24th and will be closed on Wednesday, December 25th in observance of Christmas!

Surgery Consent

Please fill out our Surgery Consent/Hospitalization Form below, and a member of our team will get back to you shortly.

caLL uS!

Forms

Surgery Consent/Hospitalization

Please Note: Any fields with * are required. Feel free to contact us if you have any questions!

Name *

First

Last

Email *

Pet's Name *

Name of Procedure: *

Phone number where authorized agent can be reached while pet is in hospital: *

Additional phone number where authorized agent can be reached while pet is in hospital:

Standard Risks and Authorization

Procedures carry the risk of complications, injury, or even death from known or unforeseen causes. No warranty or guarantee is being made regarding results or cure. Knowing that all reasonable precautions have been taken, you have been advised of and understand the nature of the procedure. The potential benefits, risks, or side effects of the procedure, including potential problems that may occur with anesthesia are understood. You acknowledge the opportunity to discuss the procedure with your doctor and understand the risks, benefits, and alternatives to the procedure. By signing this document, I am agreeing that I have received all the information I desire regarding the aforementioned procedure. I authorize and consent to the performance of warranted anesthesia and the procedure listed above. I understand unforeseen events may necessitate an extension of the foregoing procedure or alternative ones than those set forth. Therefore, I consent to and authorize the performance of such procedures/operations as deemed necessary by the veterinarians' professional judgement. *

Clear Signature

Signature

Date *

Financial Responsibility

I have been presented with an estimate of charges for the procedure as listed above prior to the treatment/procedure(s) being performed. I understand that every effort is made to honor the good faith estimate. I understand that FULL PAYMENT is due upon completion of the procedure, regardless of the outcome. I also understand that unforeseen circumstances may arise and keeping within the range of the estimate may not always be possible. In cases where possible, the staff will attempt to contact you prior to changes greater than 10% of the agreed upon estimate of cost. I understand I am responsible for the payment of any additional fees incurred. *

Clear Signature

Signature

Date *

CPR/DNR (Resuscitate or Do Not Resuscitate)

The vast majority of procedures and hospitalizations have good outcomes and proceed according to plan. In the unexpected event of a sudden decline of your pet’s health, we want to be prepared to respond in a manner that meets your wishes and fulfills your emotional and financial needs. CPR/Resuscitation may include establishment of an airway via insertion of an endotracheal tube, IV catheterization, administration of IV fluids, injections of medications, performing chest compressions, or delivery of intracardiac medications. Animals that have survived cardiac arrest and have been successfully resuscitated are extremely critical and unstable. Management of the post arrest patient requires vigilant monitoring and technical expertise and the outcome is uncertain. PLEASE CHOOSE ONE BELOW

CPR/Resuscitate

I consent to all costs incurred during the process of resuscitation of my pet. I understand that I will incur charges beyond those included in my agreed upon estimate. I agree to additional charges up to $500.00 should the CPR process be started prior to contacting me.

Owner Name

First

Last

Signature

Clear Signature

Date

DNR/Do Not Resuscitate

I decline CPR in the event that it is deemed necessary for the survival of my pet. I understand that by signing this “Do Not Resuscitate” order on my pet, the medical staff will not perform CPR or give possibly life-saving medications.

Owner Name

First

Last

Signature

Clear Signature

Date