Procedure Consent Form

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.

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)

Nail trim and ear clean included with all anesthetic procedures.

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? (including flea/tick/heartworm prevention)

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 may 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 am the owner or agent for the animal described above, I have the authority to execute this consent. The nature of these procedures has been explained to me and I fully understand what is involved. I acknowledge that I have read these conditions and hold myself bound thereto. I hereby give permission for The Kingsway Animal Hospital to administer an anesthetic or sedative to my pet and perform the procedures detailed above.

I have read and agree.

I understand that every anesthetic contains some degree of risk to the patient. This risk increases with age, the patient being overweight, and some pre-existing medical conditions. Every patient undergoes a full physical examination before administration of an anesthetic or sedative. Some conditions may not be evident upon examination so pre-anesthetic blood testing prior to anesthesia is recommended. I further understand that during the course of the procedure, unforeseen conditions may arise that may necessitate the performance of additional procedures.

I have read and agree.

I understand that all costs associated with this procedure must be paid in full on discharge of the patient. I agree to pay any debtor costs incurred in the collection of any outstanding fees. I am aware that this veterinary facility does not provide 24-hour per day monitoring of patients. I understand that I am responsible to keep in contact to enable the staff to inform me of the progress, costs incurred, and additional treatment involved of my pet.

I have read and agree.

Would you like pre-anesthetic blood testing prior to your pet's anesthesia to be done?

YesNoMy pet has already had pre-anesthetic blood testing in the past 4 months

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

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

May The Kingsway Animal Hospital use photos of your pet for educational and social media purposes?

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

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.

Signature