Surgical Consent Form

20035 N. John Wayne Pkwy

Maricopa, Az 85138

(520)568-2224

Kelly Larson, DVM

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Contact number in case of an emergency*

Area CodePhone Number

Pet's Name*

Procedure(s) *

Has your pet eaten in the last 8 hours?*

YesNo

Has your pet vomited or had diarrhea in the last 24 to 48 hours?*

YesNo

Is your pet currently on any medications? Please list below. (This includes aspirin, supplements, herbal remedies, etc.)*

Has your pet had any previous or have any current conditions we should be aware of (i.e. heart condition, liver or kidney disease, diabetes, valley fever, epilepsy [seizures], allergies to any medications, anesthesia, or vaccinations)? If yes, please explain.*

If your pet is not current on their vaccines it is our hospitals policy to update them. These vaccines must have been given by a licensed veterinarian in order for our hospital to recognize them.

Is your pet current on vaccinations, especially the rabies vaccine?*

YesNo

May we obtain records from your previous veterinarian if vaccines were done somewhere else? If so, please provide name and phone number below.*

Would you like your pet micro-chipped for $45 while it is here? *

This form is an authorization to perform the above listed procedure(s). The person signing verifies that they are the legal owner and are responsible for any and all charges at time of service (in emergencies-pet sitter or caregiver is an authorized person). Any anesthetic procedure does pose a risk to the patient, and despite all precautions taken by Maricopa Animal Hospital and their staff, medical intervnetion may be necessary. By signing this authorization, the undersigned is stating that they understand all risks and assume full financial responsibility for charges incurred to be rendered at time of service. Maricopa Animal Hospital is not a 24 hour facility - I understand that if my pet requires hospitalization overnight, there will not be a staff member attending.

I hereby certify that I am the owner of the above-named animal or am responsible for it and have the authority to execute this consent. I agree to indemnify and hold Maricopa Animal Hospital harmless and against any and all liability arising out of the performance of any of the procedures referred to above. *

Date*

Date