Caledon vet - Surgical Consent Form

Pets Name*

Pets Age*

Pets Breed*

Pets Color*

Pets Sex*

YesNo

If yes, please detail below.

YesNo

If yes, please explain.

YesNo

If yes, please explain.

YesNo

If yes, please explain.

YesNo

If yes, please list them here including dose and frequency*

YesNo

If yes, please list here*

YesNo

I understand

Surgery Date*

Date

Procedure(s) to be performed*

If your pet is having a surgery on one of their limbs, please confirm location ofsurgery (if applicable)

Owner Name*

First NameLast Name

Phone Number where you can be reached on the day of surgery*

E-Mail Address

example@example.com

In the case of an emergency where you cannot be reached, please provide us with the name and number of an emergency contact for your pet.

Name

Phone Number

I, the undersigned, being 18 years of age or older, and as the authorized owner or representative, understand the general nature and benefits associated with the procedure/treatment. I hereby authorize the personnel of Caledon Mountain Veterinary Hospital to carry out all procedures described herein, or any other procedures required by the condition of my petI understand the associated risks, complications, or side affects with the scheduled procedure or treatment. I understand that there is some risk involved with any medication given, any procedure performed, and with general anesthesia. In particular, I have been advised that there is a risk of death every time an anesthetic and/or surgery is performedI understand the Veterinarians are diligent in assessing each patient's current health status to create an appropriate treatment plan, but that there may be adverse events that are not predictable even after assessing a patient's current health status. I understand that all procedures will be performed to the best of the abilities of the hospital staff but that there can be no guarantee as to my pets condition, reaction to, or the outcome of any medication given or procedure/treatment undertaken.I understand that auxiliary staff (Veterinary Assistants, Registered Veterinary Technicians) and other Veterinarians may provide some of the treatment and care for my pet.I understand that Caledon Mountain Veterinary Hospital does not have staffing coverage available on site to monitor patients after regular office hours.I have been (or will be) provided with an estimate and I understand that I am responsible for all charges incurred for the care of my pet and that payment is due at the time services are rendered.

I give permission to initiate reasonable resuscitation and stabilization of my pet and contact me as soon as it is safe to do so.I DO NOT give permission to attempt resuscitation for my pet without contacting me priorI DO NOT give permission to attempt resuscitation for my pet at all.

We love to share pictures of our adorable patients!
If we were to take a picture of your pet we would like your permission to use it in our social media content, promotional materials and/or publicity efforts. These photographs may be used in publications, print ads, direct-mail pieces, electronic media (e.g. video, Internet, Web site) or other forms of promotion in perpetuity without remuneration or further consent. Your pet’s name may be shared but your identifying information would not be
No, I DO NOT give permission for my pets photographs to be taken Yes, I give my permission for my pets photograph to be taken and used for the purposes indicated above*

Signature*

Today's date*

Date