Surgery Admission Checklist 2021

Authorization

I verify I am the owner (or authorized agent for the owner) of the named pet and authorize the above procedure to be performed by New Baltimore Animal Hospital. I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure as directed by the veterinarian.
I agree to be responsible for all charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital. I understand no staff will be attending to my pet overnight (pets needing special care may be referred to a 24-hour hospital).
I have been advised as to the nature of the procedure to be performed and the risks involved. No guarantees have been made regarding the outcome or cure. I understand that there is always a risk associated with any anesthetic episode, even in apparently healthy animals, and have discussed my concerns with the veterinarian. The veterinarian has provided me the opportunity to ask questions and receive answers regarding the procedure. Procedure risks include serious bodily injury, (including, but not limited to: eye injuries, broken teeth, broken jaw) or death. I understand it may be necessary to provide medical and/or surgical procedures, which are not anticipated for the safety or care of my pet. I hereby consent to and authorize the performance of such life saving and/or additional procedures as are necessary in the veterinarian's professional judgement. I accept responsibility for any result in additional charges.
In the event of an unforeseen emergency, we will attempt to reach you without delay. Very rarely do emergencies happen and we want to know your preference if no one can be reached. Please select your preference below: *

Please PROCEED with extreme life-saving measures. I accept responsibility of all costs incurred. Please DO NOT PROCEED with life-saving measures. I accept responsibility of all costs incurred.
Phone Numbers:

Please list where you can be reached today during the procedure or in the event of an emergency.

Also, after surgery and once your pet is awake, we will try to contact you with a progress report.

I have read and understand the information printed above.
Contact Name: *

First Name Last Name
Date

Month Day Year
Date
Phone Number: (number we will call FIRST) *

Area Code Phone Number
Phone Number: (number we will call SECOND)

Area Code Phone Number
Signature

Clear
May we text you updates/pictures about your pet while here in surgery?

Yes No
Mobile Number for text messages:

Area Code Phone Number
Should be Empty: