Authorization for Anesthesia and/or Surgery

Clients Name

First NameLast Name

Pets Name

Patients Name

Brief description of Anesthetic/Surgical procedure(s) to be performed:

I, the undersigned owner (or agent for the owner) of the pet identified above, certify that I AM eighteen years of age or over and I authorize the veterinarians at the Pet Doctors of Sherman Oaks to perform the above procedure(s). I understand that some risks, up to and including death, always exist with anesthesia and/or surgery. I have been encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. My signature on this form indicates that any questions I have regarding the following issues have been answered to my satisfaction:

The reasonable medical and/or treatment options for my pet.
Sufficient details of the procedures to understand what will be performed.
How fully my pet is expected to recover and how long it may take.
The most common and serious complications.
The estimate of fees for all services.

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I agree to pay a deposit of 75% of the estimated fees, and I assume financial responsibility for the remaining fees, and will provide payment via cash or credit card at the time my pet is discharged from the hospital. Should unexpected life-saving emergency care be required and the hospital staff is unable to reach me, the staff:

Please Check One Box Below to Indicate Your Answer :

HAS MY PERMISSIONDOES NOT HAVE MY PERMISSION

to provide such treatment. Furthermore, I agree to pay for such services.
I have read and fully understand the conditions set forth above.

Signature

Date

The best contact number(s) to be reached at while your pet is in our care (the day of the procedure):

Phone Number(s)