AuthorizationFor Anesthetic Procedure(s) and/or Surgery Form

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Authorization for Anesthetic Procedure(s) and/or Surgery

Please fill out this form as completely and accurately as possible so we can get to know you and your pets before your visit.

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Client's Name *

Pet's Name *

Anesthetic and medical or surgical procedure(s) to be performed:

The reasonable medical and/or surgical treatment options for my pet
Sufficient details of the procedures to understand what will be performed
How fully my pet will recover and how long it will take
The most common and serious complications
The length and type of follow-up care and home restraint required
The estimate of the fees for all services
Any necessary payment arrangements

I, the undersigned owner or agent of the owner of the pet identified above, certify that I am eighteen years of age or over and authorize the veterinarian(s) at this practice to perform the above procedure(s). I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. My signature on this form indicates that any questions I have regarding the following issues have been answered to my satisfaction: The reasonable medical and/or surgical treatment options for my pet, sufficient details of the procedures to understand what will be performed, how fully my pet will recover and how long it will take, the most common and serious complications, the length and type of follow-up care and home restraint required, the estimate of the fees for all services, and any necessary payment arrangements. *

I understand that Pinnacle Animal Hospital recommends pre-operative blood work be performed for all elective procedures. If I elect to not have this testing performed, please initial here *

If my pet is not microchipped, I elect for him/her to have one placed while under sedation. (copy) *

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that veterinary medicine is not an exact science and that no guarantee or warranty has been made regarding the results that may be achieved. I agree to pay a deposit of _______% of the estimated fees, assume financial responsibility for the remaining fees, and provide payment via cash, credit card, or check at the time my pet is discharged from the hospital. Should unexpected life-saving emergency care be required and the hospital staff is unable to reach me, the staff have my permission to provide such treatment and I agree to pay for such services. *

In the event my pet is hospitalized beyond the first day at this facility, I understand that veterinary care during nighttime hours and/or weekends is provided at the discretion of the attending veterinarian. Continuous presence of personnel may not be provided during these hours. If I desire that my pet have supervision when this facility is closed, I elect to a) _____ pick up my pet and provide such care in my home, in which case I accept all risks of adverse effects or b)____ have him/her transferred to a local emergency clinic where overnight veterinary supervision is available at my expense. *

I accept that veterinary medicine is an inexact science and that no guarantee of successful treatment has been made. I have read and understand the nature of the above procedures and give my consent to proceed. *

Phone number(s) for today

Phone Numbers for today *

Phone number(2)

Signature of Owner or Authorized Agent *

Date *

Name

AuthorizationFor Anesthetic Procedure(s) and/or Surgery Form

Authorization for Anesthetic Procedure(s) and/or Surgery

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