Surgery AMA

Date*

Date

Pet Name*

Color*

Breed*

Date of Birth (or approximate age)*

Male or Female?*

Dog or Cat?*

Client Phone Number*

Client Name*

First NameLast Name

Client E Mail Address*

example@example.com

Reason for Medical Advice to Delay Surgery*

Consent for Surgery Against Medical Advice

Consent for Surgery Against Medical Advice (heart murmur)

I am the owner or the agent for the owner of the pet named above. I have been advised that this pet has a heart murmur. The veterinarian has strongly recommended a cardiac consultation prior to surgery. I understand that there is an increased anesthetic risk with a possible outcome of death. I am declining a cardiac consultation and would like the surgery done against medical advice.

Consent for Surgery Against Medical Advice (bloodwork needed)

I am the owner or the agent for the owner of the pet named above. The veterinarian has strongly recommended blood work for the above mentioned pet prior to surgery. I understand that my pet can have underlying problems that cannot be seen on physical exam and that can cause an increased anesthetic risk with a possible outcome of death. I am declining blood work and would like the surgery done against medical advice.

Consent for Surgery Against Medical Advice (abnormal lab values)

I am the owner or the agent for the owner of the pet named above. The veterinarian has strongly recommended a complete workup for this pet due to certain abnormal lab values. I understand that my pet may have serious underlying problems that can cause an increased anesthetic risk with a possible outcome of death. I am declining the work-up and would like the surgery done against medical advice.

Consent for Surgery Against Medical Advice (URI or other respiratory issues)

I am the owner or the agent for the owner of the pet named above. The veterinarian has strongly recommended postponing surgery until my pet is healthy. I understand that respiratory conditions like upper respiratory infections increase anesthetic risk with a possible outcome of death. I also understand that the stress from the surgery can make the problem worse. I would like the surgery done on my sick pet against medical advice.

Consent for Surgery Against Medical Advice (underweight)

I am the owner or the agent for the owner of the pet named above. The veterinarian has strongly recommended postponing surgery until this pet has gained weight or undergone a complete work-up. I understand that my pet may have an underlying problem causing the low body weight which can also increase anesthetic risk with a possible outcome of death. I also understand that the stress from the surgery can make pre-existing medical problems worse. I would like the surgery done on my thin pet against medical advice.

Consent for Surgery Against Medical Advice (overweight)

I am the owner or the agent for the owner of the pet named above. The veterinarian has strongly recommended postponing surgery until this pet has lost weight or undergone a comprehensive physical exam with blood work including thyroid values. I understand that my pet may have an underlying problem causing the high body condition score (ie/the obesity) which can increase anesthetic risk with a possible outcome of death. I would like the surgery done on my thin pet against medical advice.