Surgical Consent Form
Today's Date
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Month
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Day
Year
Client's Name (pet owner or party responsible)
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First
Last
Patient's Name
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Contact Number
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Format: (000) 000-0000.
Email Address
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Referral Hospital
Attending Veterinarian (DVM)
First
Last
I, as the owner or party responsible for the patient listed above, hereby authorize the doctors and staff of Jewel Veterinary Surgery LLC to perform the following procedure(s):
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At this location (select one):
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Left
Right
Both
Not applicable
I understand that anesthesia will need to be administered to accomplish the surgical procedure(s). The Attending Veterinarian and referring hospital will be responsible for monitoring and recovering the Patient during this anesthetic event.
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I have read and understand.
It has been explained to me that conditions may arise during this procedure(s) whereby a differing or additional procedure(s) may need to be performed to prioritize the Patient's safety and well-being. I understand that efforts will be made to contact me prior to such procedure(s) being performed, but there may be instances where it is in the best interest of the Patient to proceed without delay and/or Client confirmation.
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I have read and understand.
I have been advised as to the nature of the procedure(s) and the inherent risks involved. I understand that complications, including but not limited to infection, swelling, edema, hemorrhage, implant failure, cardiac arrest and death, could result. I acknowledge that no guarantee can be or has been made as to any long- or short-term result or cure. While uncommon, some complications may require additional treatment or surgery, at an additional cost.
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I have read and understand.
I have been advised that strict adherence to the post-surgical care plan outlined by Jewel Veterinary Surgery LLC and/or my Attending Veterinarian is crucial to minimizing potential complications and/or adverse side-effects. These include but are not limited to restricting exercise, abstaining from bathing or swimming, and wearing an e-collar. I understand that the follow-up care will primarily be performed by my Attending Veterinarian.
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I have read and understand.
Jewel Veterinary Surgery LLC occasionally features Patients on their website, social media channels (Facebook, Instagram, YouTube, etc.), and/or publications (in print or online). In the interest of educating other pet owners, veterinarians, and veterinary technicians on the benefits of certain surgical procedures (and celebrating Patient success stories!), please indicate your intent in sharing photos and/or videos of the Patient. (We may mention the Patient's "first" name, but NEVER the Client's last name.)
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I grant permission.
I do not grant permission.
Client Signature (patient owner or party responsible)
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*** You must use your mouse or touchpad to WRITE your full signature here. Simply clicking in the box does not authorize Jewel Veterinary Surgery LLC to provide surgical services. ***
Please verify that you are human
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SUBMIT
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