Client Name *

First

Last

Patient Name *

Phone number at which owner can be reached today or tomorrow: *

Additional number

Would you like to be contacted by text or phone call before the procedure? *

Text
Call
Either

If text, what number would you like to be texted at?

After procedure:

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

Text
Call

Is your day flexible for pick up time? *

Yes
No

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

Confirmation of surgical site/side (if applicable):

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

I have read and agree

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

Yes
No
Already has one

When did the patient last have anything to eat or drink? *

Will your pet be given medications on the morning of their procedure? *

Yes
No

Please list the medication(s) given, dose and time given:

Does your pet take any other medication(s) or supplement(s), please specify and note last time given.

Does your pet have any allergies?

Has your pet had any previous anesthetic complications? *

Yes
No

For post-operative medication, do you prefer pills or liquid ? *

Pills
Liquid

Any other concerns/procedures that we should know about?

Do you have any additional questions about the procedure or estimate/consent?

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

I have received, read and understand the estimate provided. *

I have read and agree to cost of procedure

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

Please type your initials. *

Date *

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Anesthesia / Surgical Consent Form

Complete the Anesthesia / Surgical Consent Form

Complete Your Anesthesia / Surgical Consent Form

After procedure:

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