Lake Seminole AH - Consent For Surgery & Treatment With Sedation Or anesthesia

1

Client / Patient Information* This field is required.

Owner's First Name

Owner's Last Name

Patient's Name

Phone

Email

2

Procedure:* This field is required.

3

Food withheld after 9:00 pm the night before procedure?* This field is required.(does not apply to rabbits, rats and other pocket pets)

Yes

No

4

Any medications given this morning?* This field is required.

Yes

No

5

If so, what was given and when?* This field is required.

6

GENERAL INFORMATION

Your pet will be given medication to ease any discomfort during recovery. Your pet may be given additional medications which will be sent home after surgery. These will be explained to you at your pets discharge appointment.
Part of preparation for surgery or treatment may involve shaving fur from the affected area of your pets body. We may also shave a small area from the legs or other locations for placement of an I.V. catheter, ease of administration of medications, or collection of blood samples if needed.

7

CONTACT INFORMATION* This field is required.Who are we calling and what number?

Name

Phone

8

Would you like to receive text updates about your pet during the day?* This field is required.

Yes

No

9

If yes, what number can you receive the text messages?* This field is required.

10

Would you allow us to post cute pictures of your pet on our Facebook page or website?* This field is required.

Yes

No

11

I am the * for the above described pet. I authorize Lake Seminole Animal Hospital to anesthetize/sedate and perform the services described. If requested, I have received an estimate that has been explained to my satisfaction. I accept all procedures done to be to the best of the abilities of the professional staff, and I realize that no guarantee nor warranty can ethically or professionally be made regarding the results or care . I authorize Lake Seminole Animal Hospital to provide veterinary services as requested or in an emergency circumstance, to follow through with necessary treatment for the well-being of my pet until further advised. I understand my financial responsibility for all services rendered. I have read, understood and agreed to authorize this consent by signing below.

12

Printed name of person admitting* This field is required.

13

Signature* This field is required.

Clear

14

Date* This field is required.

Date