Surgery Consent Form

Owner's Name*

First NameLast Name

Owner's Phone number*

Please enter a valid phone number.

Owner's Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Pet's Name*

Species*

Sex*

I, the undersigned, or owner's agent, of the pet identified above, certify that I am over eighteen years of age, and thereby consent to the examination/testing of my pet by staff veterinarians at Four Corners Veterinary Hospital.

I understand that an estimate of the costs for veterinary services will be provided to me and that I am encouraged to discuss all fees attendant to such care before services are rendered and during my pet's ongoing medical treatment. I assume financial responsibility for the balance of all services rendered on cash, credit card, or check basis at the time my pet is discharged from the Hospital.

I further agree that I, or an authorized agent of mine, will pick up my pet and pay for all accrued charges at the time of discharge.

I understand that some risks exist with anesthesia and that I am encouraged to discuss any concerns I have about those risks with my attending Veterinarian before the procedure is initiated. Should some unexpected life-saving emergency care be required, Four Corners Veterinary Hospital

Type a question*

HAS my permission to provide such treatment and I agree to pay for such care as listed above.DOES NOT have my permission to provide such treatment as listed above.

Signature*

Date*

Date