SURGICAL CONSENT FORM

Mountainview Animal Hospital 4141 US Route 9 Hudson, NY 12534

Owner *

Date *

Address *

Phone *

Cell/Other Auth Person #

Patient *

Breed/Color *

Sex *

Birthday/Age *

Treatment, Surgery and/or Procedure(s) to be performed while my animal is under care *

I, being responsible for the above-described animal, have the authority to grant Mountainview Animal Hospital my consent to receive, prescribe for, test, sedate and/or perform an exam upon my pet. I understand that the procedure is stated above. You are to use all reasonable precautions against injury, escape, or death of my pet, but you will not be held liable or responsible in any manner in connection therewith as it is thoroughly understood that I assume all risks.

By signing below I also understand that Mountainview Animal Hospital does NOT do billing and I am responsible for payment upon pick up of my pet.

I understand that if I have any financial restrictions/limitations that it is my responsibility to let the staff of Mountainview Animal Hospital know, prior to starting treatment.

We will be happy to provide you with an estimate.

Authorized Person(s) Signature *

Clear

*Please note that we are not a 24-hour care facility. If you would like for your pet to have 24- hour care we will refer you to one of the emergency clinics.