Surgery & Anesthesia Consent

Surgery and Anesthesia Consent
I am the owner of *

Patient's NameOwner's Last Name
The reason why the operation / procedure is necessary, its advantages, possible complications, and possible alternative modes of treat ment have been discussed with me.
I have the authority to execute consent for the Surgical / Medical Procedure known as:*
If applicable, I have notified the insurance company and permission to proceed was received on:*

MonthDayYear
Date
With full understanding of the above, the undersigned owner / agent authorizes the De Cillo Equine Veterinarian to perform, under any anesthetic deemed advisable, said operation / procedure.

I understand that further procedures may be therapeutically necessary based on findings during the operation/procedure. I consent to those procedures, their additional cost, and any unreported lifesaving emergency care deemed necessary by the attending Veterinarian.

I understand that risks and potential complications exist with anesthesia and surgery. These include, but are not limited to:

· Abnormal reaction to anesthetic agents, self inflicted injury during anesthesia recovery (i.e., fractured leg, head trauma), muscle and nerve damage, dehiscence of incision, colic, post operative infection, equipment failure, and death.

· Surgically removed tissues may be processed at additional costs to establish an accurate diagnosis.
I understand the estimated charge I was given for this procedure may change depending on the findings and diagnostics and full payment (less any deposit) is due at the time of discharge. The estimated price I was given for this procedure is:*
I also understand that if there are complications or requires a more complicated approach, the price can be as much as:
Acknowledgement

I have read this agreement "Consent for Surgery and Anesthesia" and fully understand its terms. I intend my signature to be an authorization for surgery and complete liability release to De Cillo Equine Clinic.
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Client Signature*

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Date Signed*

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Surgery and Anesthesia Consent