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Client Name

Date

Phone Number

Email

Address

City

State

Zip Code

Patient Name

Breed

Sex

Color

Current Weight

Procedure(s)

Anesthetic and surgical procedure(s) to be performed:

Anesthesia / Surgical Consent

I, the undersigned owner or agent of the pet identified above, authorize the staff of North Greenville 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.

Permission

I understand that the attending veterinarian will make every effort to contact me regarding treatment in the case of unforeseen emergencies. If unable to contact me, the staff may or may not have my permission to proceed with life-sustaining procedures.

I give my permission [yes]
I do not give my permission [no]

Acknowledgement of Risk and Responsibilities

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved.

I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow-up radiographs, re-check physical exams, and additional surgery due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions.

A complete physical exam will be performed on your pet prior to the surgical procedure if it has been longer than 30 days since the last exam. However, this may not identify all systemic or metabolic problems. For this reason, your pet will have a pre-anesthetic blood panel to evaluate major organ functions prior to anesthesia.

Agreement

By submitting this form, I agree I have read and fully understand the terms and conditions set forth above.