Surgical Consent Form

Surgical Consent Form
Owner's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Patient's Name*

First NameLast Name
Species/Type*

DogCat
Sex*

MaleFemale
Neutered/Spayed*

YesNo
Age or Birthday*
Surgery/Anesthesia Consent
I hereby authorize *Veterinary Emergency Center/Leshem Veterinary Surgery to use general anesthesia and perform the services listed on the estimate. I acknowledge that I am the owner/authorized agent of the animal described above. I understand that surgery poses a risk to this animal, regardless of health status. In the event of unforseen complications, I give permission to *VEC/LVS to take reasonable measures in treating my pet during anethesia/surgery and accept all charges that are incurred as a result of such action. The surgery and relevant costs have been discussed and explained to my satification.
Signature*

Clear
Unexpected Complications

Please choose ONE option
If unexpected complications arise (choose ONE option):*

CPR: I grant *VEC/LVS permission to perform life saving efforts INCLUDING Cardiopulmonary Resuscitation (CPR) for my animal until I can be reached or the veterinarian on staff deems it necessary to discontinue efforts. I understand I will be contacted as soon as possible. I understand and consent to any additional costs, between $500-$800 that may be incurred above and beyond the estimate due to these efforts. I am aware this still could result in the death of my animal and therefore release and discharge *VEC/LVS from any and all liability.DNR: I grant *VEC/LVS permission to perform life saving efforts BUT WITHHOLD Cardiopulmonary Resuscitation (CPR) for my animal until I can be reached. I understand I will be contacted as soon as possible. I understand and consent to any additional costs that may be incurred above and beyond the estimate due to these efforts. I am aware this still could result in the death of my animal and therefore release and discharge *VEC/LVS from any and all liability.
Best Contact Numbers

All numbers provided must belong to an individual authorized to make medical decisions on behalf of the animal listed above in case of emergency.
Phone Number*
Please enter a valid phone number.
Phone Number
Please enter a valid phone number.
Phone Number
Please enter a valid phone number.
Is your pet currently taking any medications?*

NoYes (please list below)
Do you have any medications at home, that your pet is not currently taking?

YesNo
Please list all medications, including strength and dosage
Please Read and Review
Please be aware that with the exception of prescribed medications we do not allow, and are not responsible for, any belongings left with hospitalized patients. This includes leashes, harnesses, collars, toys, blankets, and carriers. Belongings left at the hospital for any reason will not be kept for longer than 7 days after check out.*

I understand and acknowledge the above statement.
I have recieved and reviewed the estimate. I consent to the services listed and acknowledge that they have been explained to me. I understand that the low and high sides of this estimate do not directly correlate to the specific number of days a patient spends in hospital as many of the aforementioned diagnostics and/or treatments take place within the first 24 hours of hospitalization.

I acknowledge that I am the owner/authorized agent of the animal described above. I understand this is a reasonable estimate. I further understand that it is possible that the final invoice may exceed the estimate by as much as 15% and does not inculde the cost of continued care should it be necessary for this animal to remain in the hospital beyond the time frame indicated on the estimate. I also understand I am accepting full financial responsibility and that the full amount due shall be paid upon discharge.

Estimated fees will be honored up to 60 days.

In the event of a default hereunder, the Veterinary Emergency Center/Leshem Veterinary Surgery is entitiled to charge and collect interest at the rate of 18% per annum, collections cost, and reasonable attorney's fees.

* For the purposes set forth herein, and reference to the VEC/LVS includes it's doctors, nurses, management, and staff.
Signature*

Clear
I will bring all of my pet's medications (currently taking or not) with me the morning of surgery, in their original vials (other than preventatives)*

I understand and acknowledge the above statement and understand that I will be charged for doses of medications that are not provided. Please initial below.
Initials*
Date*

MonthDayYear
Date
Should be Empty:

Surgical Consent Form

Surgery/Anesthesia Consent

Unexpected Complications

Best Contact Numbers

Please Read and Review