Surgical Authorization Form

Save time during your next surgical authorization appointment. Complete your required form online from any device at any time before your visit.

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Surgical Authorization Form

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

Name *

First

Last

Email *

Primary Phone *

Secondary Phone

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Sex

Male
Neutered Male
Female
Spayed Female

Procedures to be performed:

I, the undersigned owner or agent of the owner of the pet identified above, certify that I am the age stated below and authorize the veterinarians at Pinnacle Animal Hospital 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. While I accept that all procedures will be performed to the best of the abilities of the staff at this facility, I certify that no guarantee or warranty has been made regarding the results that may be achieved. I agree to pay a deposit of 50% of the estimated fees. I agree to assume financial responsibility for the remaining fees and will provide payment via cash or credit card 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 should follow my permission stated below to provide such treatment and I agree to pay for such service. I understand that during the performance of medical, surgical, or anesthetic procedures, unforeseen conditions may be revealed that necessitate more extensive, costly, or different procedures than originally planned. If staff at this veterinary practice are unable to reach me, I hereby consent to and authorize the performance of such procedures as are necessary and desirable in the professional judgment of the attending veterinarian.

I have read and accept the financial policy.

Please check one:

I, the owner am above the age of 18.
I, the owner am under the age of 18

Please check one:

The staff has my permission to provide such treatment and I agree to pay for such service
The staff does not have my permission to provide such treatment and I agree to pay for such service

Date

Surgical Authorization Form

Surgical Authorization Form

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