Procedure Consent Form

Procedure Consent Form
Owner Name

Prefix First Name Last Name
Pet Name
Species
Breed
Age/Date of Birth
Sex
Today's Surgical Procedure - Please check one

Dental Phase 1 (cleaning and radiographs only) Dental phase 2 (surgical extractions) Spay Neuter
Has your pet eaten after 10 PM last night?
Has your pet had any medications or supplements recently
If you answered yes to the question above, please list the medications or supplements your pet has taken
Best phone number to reach you today

Area Code Phone Number
I understand the above anesthetic and surgical, diagnostic or therapeutic procedures may involve risk of complications, injury or even death, from both known and unknown causes and no warranty or guarantee has been either expressed or implied as to result or cure. Furthermore, I authorize the hospital staff in an emergency situation, to follow through with such procedures as are necessary for the well being of my pet on a continuing basis until further communication with me. I agree to assume financial responsibility for all routine and emergency services rendered.
In the unlikely event, Pet's Name should experience cardiac arrest during his/her time at Cane Bay Veterinary Clinic, I request
*

DNR - Do Not Resusciate. This means no attempt will be made to revive your pet in the unlikely event of cardiac arrest. CPR - Cardio-Pulmonary Resuscitation. This means the staff will immediately implement life saving procedures in an attempt to revive your pet in the unlikey event of cardiac arrest; however, this does not guarantee a successful outcome. This procedure will incur additional costs and you will be expected to pay these costs regardless of outcome.
I agree to meet the costs of all treatment at the time of discharge. I understand the risks and complications of these procedures, which have been explained to me by the Veterinarian.

All accounts are payable at the time of consultation unless a prior arrangement has been made.

Your signature below constitutes your acknowledgement that (i) you have read and agreed to the above, (ii) the procedure(s) have been explained to your satisfaction and that you have all the information that you desire, (iii) you have had the chance to ask questions, and (iv) you authorize and consent to the performance of the procedure(s) and to the administration of anesthesia.
Signature (Owner of Pet)

Clear
Today's Date

Month Day Year
Date
If your pet is receiving a microchip today, please provide the following information so that we can properly register his/her microchip
Owner's Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Email
example@example.com
Should be Empty:

Procedure Consent Form

If your pet is receiving a microchip today, please provide the following information so that we can properly register his/her microchip