ANIMAL HEALTH CARE CENTER GENERAL SURGICAL CONSENT FORM

1
Pet Name* This field is required. Please type your Pet's Name as it appears in our system
2
Client Name* This field is required. Please type your FIRST and LAST name
3
I, the undersigned, do hereby certify that I am the Owner (or duly authorized agent for the Owner) of the above described animal and do hereby give Animal Health Care Center's doctors, agents, and/or representatives full and complete authority to perform the surgical procedure described below. I do hereby and by the presence forever release the said doctors, agents, and/or representatives from any and all liability arising from said surgery on the described animal. Drop off is at 7:30am.
4
Please Type your INITIALS in the following consents.
5
I understand that during the performance of the foregoing procedure(s) or operation(s), unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure(s) or operation(s) or different procedure(s) or operation(s)than those set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) operation(s) as are deemed necessary in the exercise of the veterinarian's professional judgment. Any additional procedure(s) will incur an additional fee to whatever estimate may have already been given. Pregnant, pyometra in heat, undescended testicles or obese pets will incur additional charges as well. I authorize the use of appropriate anesthetics and other medications, including those for pain. I understand that hospital support personnel will be employed as deemed necessary by the veterinarian.* This field is required.
Please type your INITIALS
6
I have been advised that all required immunizations must be current at the time of the surgery. Any not current, per standard, will be given upon admission.* This field is required.
Please type your INITIALS
7
I understand that my animal was not to eat or drink any water 10 hours prior to be anesthetized. I do not hold Animal Care Center responsible of any complications due to the consumption of food or water prior to surgery that arise my pet is under anesthesia.* This field is required.
Please type your INITIALS
8
I understand that veterinary medicine is not an exact science and that no guarantee or warranty has been made the results that may be achieved. I am encouraged to discuss any concerns I have about those risks with the veterinarian before the procedure(s) is/are initiated. Anesthetic Risks: We do not anticipate any in your pet but, on adverse events can occur including: 1. Allergic reaction to the anesthetic agents 2. Heart rhythm abnormalities 3. reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like in humans, on the very occasions, general anesthesia can result in death. Every effort is made to make anesthesia as safe as possible vital sign monitoring and use of the most up to date anesthetic agents and equipment. A catheter and fluid therapy administered to patients undergoing anesthesia as determined by your veterinarian. This therapy helps regulate temperature and blood pressure, provides cardiovascular support and hydration, as well as provides emergency access to pet if needed.* This field is required.
Please type your INITIALS
9
Having normal blood test results does not guarantee absence of risk, but being aware of any subclinical conditions affect the decision to proceed or not and, if the decision is made to proceed, awareness of underlying conditions will us to tailor the anesthetic protocol to make the procedure as safe for your pet as possible. Any required bloodwork be placed on your estimate. You are always welcome to request additional bloodwork.* This field is required.
Please type your INITIALS
10
Would you prefer us to Call, Text or Email you while your pet is with us. Please be available between 8am-2pm.
11
Would you prefer us to Call, Text or Email you while your pet is with us. Please be available between 8am-2pm.* This field is required.
Call
Text
Email
12
Phone Number* This field is required.Please be sure you can be reached at any time on this number between 8a-2pm the day of surgery.
Please enter a valid phone number.
13
Phone # to textPlease be sure you can be reached at any time on this number between 8a-2pm the day of surgery.
14
EmailPlease be sure you can be reached at any time at this email between 8a-2pm the day of surgery.
example@example.com
15
By signing below, I am indicating that I have read and understand this authorization and consent. I agree to pay the estimate at the time of drop off and understand this is an estimate and prices may change after procedure is completed. If there is a remaining balance, I agree to pay for all services rendered at the time the patient is discharged.
16
Signature* This field is required.
Clear
17
Date* This field is required.
Date
Month
Day
Year
Should be Empty: