Procedure Consent Form

Date

Pet Name

Owner Name

First NameLast Name

Owner Email

example@example.com

Phone number at which you can be reached during the procedure?

Please enter a valid phone number.

Additional number that you can be reached at?

Please enter a valid phone number.

Emergency Contact

First NameLast Name

Emergency contact phone number?

Please enter a valid phone number.

Requested Procedure(s)

Have you received an estimate for this procedure within the last 90 days?

YesNo

Have you given your pet any medications or supplements in the past week?

YesNo

If you answered yes to the question above, please list the medications or supplements given:

Post-operative medications vary greatly for each pet's procedure; therefore, a cost has not been provided on your pet's estimate. These may include antibiotics and/or anti-inflammatories.

I understand that additional fees may be incurred if it is recommended that my pet receive post-operative medications.

I am not to feed my pet after 12 midnight the night before the procedure.

I have read and agree.

Any other concerns or allergies to note?

I understand that unforeseen conditions may be revealed during the identified procedure(s) which, in the opinion of the attending veterinarian, may require more extensive or different procedures or treatments. I understand that reasonable efforts will be made to contact me to explain these procedures or treatments and obtain instructions regarding them. However, if the efforts are unsuccessful, I authorize performance of any life sustaining procedures or treatments, which are deemed necessary in the professional opinion of the attending veterinarian.

Yes, I give my permission.No, I do not give my permission.

I understand that some risks always exist with anesthesia and/or surgery (including, but not limited to, allergic reactions, respiratory compromise, cardiovascular effects, post operative complications) and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedures or treatments are initiated.

I have read and agree.

If pre-anesthetic blood work has been recommended, I understand that proceeding with the testing would provide insight into my pet’s health thereby improving the safety of anesthesia.

Yes, I would like to proceedNo, I decline

If a cardiac ultrasound has been recommended, I understand that proceeding with the testing would provide insight into my pet’s health thereby improving the safety of anesthesia.

Yes, I would like to proceedNo, I decline

Are there any other procedures that you would like performed on your pet during their appointment?

I do hereby give the veterinarians of the Kingsway Animal Hospital and their assistants, complete authority to perform the above procedure(s), which I understand, or which have been explained to me. If you have not been informed regarding the above procedures to your satisfaction or do not understand, it is your responsibility to inquire at the time of signing of this document.

Are there any medications/supplements you wish to pick up for your pet?

The Kingsway Animal Hospital takes your privacy seriously. As per the federal Personal Information Protection and Electronic Documents Act (PIPEDA), we collect, use, and disclose personal information only to the extent necessary for the goods and services we provide. The primary purpose for collecting personal information is to provide veterinary services.

As part of our environmentally friendly initiative, we are going paperless. As such, you will be emailed your pet's take home instructions following their procedure. Would you enjoy a printed copy instead?

YesNo

Signature