Surgery Consent Form

"*" indicates required fields

Owner*

Pet's Name*

PHONE NUMBER WHERE YOU CAN BE REACHED AT ALL TIMES ON DAY OF APPOINTMENT. The Doctor must be able to reach you if there is a question during the procedure.

Phone Number*

MICROCHIP to return lost pets: A microchip is now available to return your pet to you quickly and safely in the event they run away. It’s the size of a grain of rice and is inserted under the skin. It causes no discomfort and remains active for the life of your pet. If your pet accidentally gets away and is taken to a shelter or animal hospital, a scanner will pick up the microchip’s number for your pet, and you will be called immediately. Lifetime registration is included.

Microchip Status

YES, I would like a microchip for my pet

NO, I would not like a microchip for my pet

My pet is microchipped – Fantastic! Make sure you have updated your contact information.

I hereby authorize performance of the following surgical or other procedure(s):

Procedure name*

Date of Procedure

MM slash DD slash YYYY

Estimate

I have received an estimate of the cost for the following procedure.

If not, I want an estimate before the procedure is done.

I understand that during the performance of the foregoing procedure(s) or operations(s), unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure(s) or operation(s) in addition to those set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) or operations(s) as are necessary and desirable in the exercise of the veterinarian’s professional judgement.

I also authorize the use of appropriate anesthetics and other medications, and I understand that the hospital support personnel will be employed as deemed necessary by the veterinarian.

The nature of such service has been described to me to my satisfaction and I realize that no guarantee or warranty can ethically or professionally be made regarding the results or cure.

Surgery Consent #1*

I understand I assume financial responsibility for all services rendered, and that payment is due on the date of procedure.

Surgery Consent #1*

I understand that there is a 48 hour cancellation policy and that I will be assessed a $300 missed appointment fee if I do not cancel or reschedule my pet’s procedure with at least 48 hours’ notice. I assume financial responsibility for the charge in this event.

Bloodwork Completed on

Bloodwork Scheduled on

Signature*

Date*

MM slash DD slash YYYY

Emergency Contacts

Primary Contact Name

Phone*

Alternative Contact Name

Phone

Emergency Care Plan

In the event that your pet requires emergency care during the stay, Best Friends Animal Hospital will make every reasonable effort to contact you at the emergency contact numbers provided. However, if you are unable to be reached prior to the time when the performance of the necessary care is deemed to be required by the attending veterinarian, the hospital staff asks your permission to provide any necessary medical care for your pet.

In the event that your pet should experience cardiac or respiratory arrest while being hospitalized, do you give consent for resuscitative efforts to be initiated until you can be contacted further and notified of your pet‘s status?

By consenting to this service, you are also acknowledging that certain fees will apply. If you are not able to be contacted immediately, resuscitation efforts will continue to be performed at the doctor’s discretion.

Please select and initial your choice below

I agree to CPR being performed in case of arrest.*

Yes

I elect a “Do Not Resuscitate” status in case of arrest.*

Yes

I have read and understand this authorization and hereby accept and agree to the terms of the consent for treatment.

Signature*

Date*

MM slash DD slash YYYY

PRE-ANESTHETIC INSTRUCTIONS

IMPORTANT: If pre-surgery bloodwork, urine, and/or radiographs have been advised, this must be completed at least 48 hours prior to surgery.

FOOD: No food after 8:00pm the night before surgery.
WATER: No water the morning of surgery.
Please walk your dog to allow time for urination and defecation before coming to the hospital.
Please bring your pet to the hospital at 7:30 the day of surgery.
Please complete the standard consent form that was emailed to you prior to coming to the hospital.
If there is any change in the status of your pet before the scheduled surgery date, please call the office as soon as possible to alert the doctor – surgery may need to be rescheduled.

Exotic Animal Instructions: Do not withhold food. Continue regular feeding.

This field is for validation purposes and should be left unchanged.