Hospitalization Consent Form

Anesthesia, Surgical, and Medical Release

Procedure(s)

I, the undersigned, certify that I am the owner, or authorized agent for the owner, of the animal indicated below. I authorize the veterinarian on duty, and assistants, to perform the procedures listed above and on the corresponding estimate (including administration of pain relief medications, sedatives, and/or anesthetics, as well as any necessary and appropriate medical, radiological, surgical, nursing, diagnostic, and/or emergency care for the animal). I have been advised as to the nature of the procedures and the potential risks. I also understand that no guarantee of successful treatment can be made.

For Dental Procedures:

Please choose ONE of the following options:

I authorize ALL diseased/deciduous teeth to be extracted as necessary

I authorize UP TO 4 diseased/deciduous teeth to be extracted without being contacted by phone prior to extraction

I request to be contacted prior to ANY diseased/deciduous teeth extractions

I understand that if I have requested to be contacted, but cannot be reached at the contact phone numbers that I have provided, no extractions/additional extractions will be done and the procedure will need to be rescheduled at a later date

Surgery/Dentistry Patients

We recommend a preliminary blood test to screen all patients that are to receive anesthesia. Many conditions including kidney disease, liver disease, anemia and diabetes can be detected with a simple blood test. If your pet has not already had a screening test prior to the procedure, we can do one today. This test costs $ ___

Blood work has been done

Yes, I want my pet to have a pre-anesthetic blood test.

No, I do not want my pet to have a pre-anesthetic blood test. I acknowledge that there may be a concealed risk that could jeopardize a successful outcome for today's procedure.

I also understand that veterinary service during nighttime hours and/or weekends is provided at the discretion of the veterinarian in charge. Continuous presence of personnel is not provided during these hours. I have read and understand the reasons for, and the risks of, the abovf and corresponding authorized procedure(s). and assume full financial responsibility for all charges and services incurred to the described animal.

Owner's name

Phone (Call this number 1st)

Phone (Call this number 2nd)

Phone (Call this number 3rd)

Today's date

Yes

What medication(s) is your pet currently taking?

When did your pet eat last?

Signature

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Hospitalization Consent Form

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