Procedure Consent Form

Your Full Name *

First Name Last Name

Email *

example@example.com

Phone Number *

Area Code Phone Number

Address *

Street Address

Unit Number

City Province

Postal Code

Patient's Name *

Species *

Cat Dog Rabbit Ferret Hedgehog Rodent (hamster, gerbil, rat, mouse, chinchilla, etc.)

Reproductive Status *

Male Male Neutered Female Female Spayed Unsure

Age *

please specify months or years

Breed *

If you are not sure you can write unknown.

Procedure Date *

Month Day Year

PLEASE READ THE FOLLOWING INFORMATION CAREFULLY, AND INDICATE YOUR CONSENT AT THE BOTTOM OF THIS SECTION.

The nature, purpose, and effect(s) of this/these operation(s) and/or procedure(s), as well as the attendant risks and alternatives, have been clearly and adequately explained to me.

I understand that there can be no guarantee as to the animal’s condition or the outcome of any procedure and/or treatment.

I understand that there is always risk inherent to anesthesia. The following precautionary measures have been recommended: fasting, intravenous fluids and pre-surgical blood work; and I have accepted or declined them as stated on the attached treatment plan.

I understand that unforeseen conditions may be revealed during the above procedures, which in the opinion of the attending Veterinarian may require more extensive or different procedures or treatments.

I understand that reasonable efforts will be made to contact me to explain these procedures and/or treatments and obtain my instructions regarding them prior to proceeding.

If the efforts to reach me are unsuccessful, I consent to such further operation(s) and/or procedure(s). I understand that I am responsible for all charges incurred.

I consent to the assistance of other hospital personnel at the Veterinarian’s direction, considered necessary or advisable by the attending Veterinarian, in whose care I hereby place my pet.

I understand that Wellesley Animal Hospital is not staffed overnight.

I understand that if my pet(s) should be found to have fleas or other external infectious parasites that s/he will be treated at my cost.

I understand that if I should leave my animal(s) for more than 3 days, or their belongings for more than 30 days, that they shall be considered abandoned and will become the property of Wellesley Animal Hospital.

I certify that I have read, have interpreted and fully understand the above, and give my consent for the procedure(s) detailed in the attached treatment plan.*

Please attach the treatment plan for which you are giving your consent here. *

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Signature: *

Clear

Deposit amount:

CAD 50% of the treatment plan total is required.

Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
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