0384 - Riverside Animal Hospital North - Anesthesia/Surgical Consent Form

Name*

First NameLast Name

Patient Name*

Email*

example@example.com

Primary Phone Number*

Please enter a valid phone number.

Primary Phone Type*

Alternate Phone Number

Please enter a valid phone number.

Alternate Phone Type

Would you like us to text you after the procedure, or would you prefer a call?*

TextCall

Anesthetic and surgical procedure(s) to be performed:*

I, the undersigned owner or agent of the pet identified above, authorize the staff of Riverside Animal Hospital to perform the above procedure(s).*

I have read and agree.

Microchip: *There is an additional fee for this procedure**

YesNoAlready has one

Nail trim: Would you like a complimentary nail trim for your pet?*

YesNo

Have you given your pets any medications or supplements in the past week?*

When was the last time fed?

Any other concerns/allergies/procedures?

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 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. 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.*

Please proceed with life-saving measures. I accept responsibility for all costs incurred.Please do not proceed with life-saving measures. I accept responsibility for all costs incurred. This is a consideration for patients who have an acute or life threatening illness.

We may identify additional problems during the dental procedure that could not be identified beforehand, broken or abscessed teeth, bone loss, deep pocketing, etc. These problems are best dealt with while your pet is under anesthesia. Please indicate how you would like for us to proceed if extractions or additional procedures are warranted: (PICK ONE)*

I authorize the veterinarian to proceed with any necessary treatment for my pet, regardless of cost.I authorize the veterinarian to proceed with any necessary treatment for my pet up to (insert below)

$ blanks

I understand I will not be contacted unless the total cost of services exceeds this amount.

I do not authorize the veterinarian to proceed with additional treatment without my consent. I understand if I am unable to be reached by phone, my pet will be recovered from anesthesia and an additional anesthetic procedure will be needed to correct the problem, which will be at an additional cost.

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.*

I have read and agree.

I am over 18 and 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 permission (yes)I do not give permission (no)

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. I have been provided an estimated cost for the procedure(s) listed above. I assume financial responsibility for the recommended services and will provide payment in full at the time my pet is discharged from the hospital. I have read and fully understand the terms and conditions set forth above.*

I have read and agree.

I certify that I am 18 years of age or older and responsible for the financial and medical decisions for the above mentioned pet.*

I agree.I disagree.

Printed Name for E-Signature*

First NameLast Name

Signature of Owner

Date *

MonthDayYear

Are You A Robot?*

Client Information

After Procedure:

Anesthesia/Surgery Consent: