Surgery/Sedation Consent & Check-In Form

SURGERY/SEDATION CONSENT & CHECK-IN FORM

Please return this form to us on or before the day of your pet's procedure
I authorize the staff of Indian Trail Animal Hospital to perform the following procedure(s) on my pet:
Patient Name*
Owner Name*
Date of Procedure*

MonthDayYear
Surgical or Medical Procedure
What medications do you have at home?
Does your pet normally get pre-visit (anti-anxiety) medications?
Best number(s) to contact you during procedure:*
Please note it is very important for us to be able to reach you during your pet's procedure.
Any other requests or questions?
ACKNOWLEDGEMENTS: (Please read and initial each statement, then sign below)
I understand that I must be reachable by phone while my pet is hospitalized.*
Please Initial
I understand that if I have an estimate more than 3 months old, it is my responsibility to request an updated version.
Please Initial
I understand all surgical, anesthetic and medical procedures contain inherent risk. I understand the success of any surgical, anesthetic or medical procedure involves a multitude of factors, many of which are beyond the control of the veterinarian and staff. I have discussed the risk and possible complications related to the above procedure to my satisfaction.
Please Initial
Please read, and then select your choice below:

I understand that during the performance of DENTAL, medical, surgical, or anesthetic procedures, unforeseen conditions or complications may be revealed that necessitate more extensive, costly, or different diagnostics or treatments than originally planned. Initial your preference in the event of additional diagnostic or treatment recommendations including dental extractions for dental procedures.
Proceed with veterinarian's recommendationsCall First
If the staff at Indian Trail Animal Hospital is unable to reach me at the provided phone number above, I hereby consent to and authorize such procedures and extractions as are necessary and desirable in the professional judgment of the attending veterinarian and understand that the cost of such procedures may increase the final bill..
Owner/Agent Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

SURGERY/SEDATION CONSENT & CHECK-IN FORM