Surgery Consent Form

DeFries Veterinary Services Surgery Consent Form

Please fill out this form in entirety to ensure we can provide your pet with the best possible care.
Pet's name
Your Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Where can we call you at while your pet is here?

Area CodePhone Number
Email
example@example.com
It is imperitive that we be able to reach you in a timely manner while your pet is in the building today. Please have your cell phone listed above available and be free to talk.
Is there anyone else we can call regarding your pet while they are here today?
Alternate Contact Name

First NameLast Name
Alternate Contact Phone

Area CodePhone Number
Reason for your pets visit today?
Please list type of surgery, any vaccines, microchip, etc
Reason for your pets visit today?
Please list type of surgery, any vaccines, microchip, etc
Has your pet had any food since midnight last night?
Has your pet been vomiting or having diarrhea?
Does your pet have any allergies?
If yes, please describe/provide more information
Has your pet ever had any adverse reaction to medication?
If yes, please describe/provide more information
Please list any medications, supplements, topical treatments your pet has received in the past 72 hours and when they were last given:
Is Your Pet Current On Vaccinations?
My pet's vaccines were administered last by:

Other
Is There Anything Else We Should Know About Your Pet?
If yes, please tell us more. If no, please note N/A
Authorizations
I verify that I am the owner (or authorized agent for the owner) of the above named pet and authorize treatment of my pet to be performed by Dr. Amy DeFries. I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that an anesthesia assistant will be employed in the procedure as directed by the veterinarian.
Initial
I have been advised as to the nature of this procedure to be performed and the risks involved. No guarantees have been made regarding the outcome or cure. I understand that there is always a risk associated with any sedation or anesthesia episode, even in apparently healthy animals, and have discussed my concerns with the veterinarian. The veterinarian has provided me the opportunity to ask questions and receive answers regarding the procedure. This risk includes serious bodily injury or death. I understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated for the safety or care of my pet. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian’s professional judgment. I accept responsibility for any result in additional charges.
Initial
I agree to be responsible for all charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital. I understand no staff will be attending to my pet overnight (pets needing special care may be referred to a 24 hour hospital).
Initial
In the event of an unforeseen emergency, we will attempt to reach you without delay. Please know that we will take every precaution to ensure that your pet is safe and healthy enough to undergo their procedure today. Any known risks will be discussed with you. However, very rarely, emergencies do happen and we want to know your preference if no one can be reached. Please check your preference:
I acknowledge my choice regarding resuscitation choice for my pet as noted above.
Initial
Should be Empty:

DeFries Veterinary Services Surgery Consent Form

Authorizations