Surgery/Anesthesia Consent

Date:

Date

Patient:

Client:   First Name * Last Name *

Emergency Contact:   First Name Last Name

Phone:    Phone Number

Dr. Luper and staff of Fur & Feather Veterinary Hospital appreciate your decision to use us as your animal health provider. Your trust in us is not taken lightly. Our goal is to always provide excellent up-to-date veterinary medicine and surgery and to treat your pet as we would our own. Because of this concern, we feel it is important to have your written consent before performing any procedure. The following is a copy of the American Veterinary Medical Association Standard Consent Form:

By filling out this form I certify that I am the owner, or agent for the owner, of the above described animal and have the authority to execute this consent

Initials* I understand that during the performance of the foregoing procedure(s) or operation(s), unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure(s) or operation(s) or different procedure(s) or operation(s) set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) and operation(s) as are necessary and desirable in the exercise of the veterinarian’s professional judgment.

Initials* I also authorize the use of appropriate anesthetics, and other medications, and I understand that hospital support personnel will be employed as deemed necessary by the veterinarian.

Initials* I have been advised as to the nature of the procedures or operations and the risks involved. I realize that results cannot be guaranteed. I do not hold Fur & Feather Veterinary Hospital liable for any illness my pet may develop that would have been prevented through recommended vaccination, laboratory testing, or other procedures.

Initials* I agree to pay for all fees incurred upon completion, and understand that no billing is available.

Initials* I understand that the doctor will call the above listed emergency contact information if any unexpected problems are discovered during an anesthetic procedure. IN THE EVENT THAT I CANNOT BE REACHED, I understand that the doctor will proceed with the optimal treatment including but not limited to extractions, mass removal, or oral surgery. I am aware that there will be additional charges associated with additional care and I agree to assume financial responsibility for any additional charges.

Initials* I agree to pay for all fees incurred upon completion, and understand that no billing is available.

Initials* I ATTEST THAT PATIENT’S FOOD WAS TO BE REMOVED BY 10PM LAST NIGHT PRIOR TO SURGERY, AND TO MY KNOWLEDGE, HASN’T EATEN ANYTHING PRIOR TO SURGERY TODAY.

Initials* I am the owner or agent for the owner of the above described animal and have the authority to execute this consent. .

Initials* I hereby consent and authorize the performance of the procedure(s) / operation(s) as in the medical care plan

Was any medication given this morning?:

Yes No

If Yes, what medication and what dosage:

Medication: blanks Dosage:

Medication: blanks Dosage:

Would like your pet to receive a Microchip today ($64.50)?:

Yes No Already Has One

Would you like to have your pet's nails trimmed today?:

Yes No

Please read and CHOOSE ONLY ONE (1). *

I authorize Fur & Feather Veterinary Hospital to perform all needed lifesaving treatments without having to contact me first. I authorize Fur & Feather Veterinary Hospital to perform only minimum lifesaving treatments until I have been contacted and continued care and cost can then be approved. I decline any treatment needed until I have been contacted and recommended care and cost is discussed with the DVM.

I HAVE READ AND UNDERSTAND THIS AUTHORIZATION AND CONSENT.

Owner/Agent Name: First Name * Last Name *

OWNER/AGENT SIGNATURE: *

Clear

DATE

Date

Staff Member:

Thank you for allowing us to care for your pets!

SURGICAL/ANESTHESIA PROCEDURE(S) CONSENT

While my pet is here, if an illness or emergency situation occurs: