Authorization Form

Surgery Consent Form

Make surgery consent for your pet hassle-free with our streamlined form, ensuring a seamless preparation process.

Surgery Consent Form

Before your pet’s surgical procedure, please complete the form below. To ensure your pet receives the best possible care, kindly provide all requested information. Please Note: All * fields are required.

Owner Name *

First

Last

Email *

Phone *

Pet's Name *

Animal’s Possessions

Procedure *

Procedure Date *

Surgery Authorization

I hereby authorize the performance of the above surgical procedure, including the placement of an IV catheter and pre-anesthetic bloodwork. The nature of this procedure has been explained to my satisfaction, and I realize that no guarantee or warranty can be made regarding the results or cure and that all procedures involving general anesthesia carry a small risk of complications, including death. If your animal becomes stressed during the blood draw or catheter placement, I authorize the veterinarians to administer sedation, at no additional cost, to allow catheter placement and a blood draw prior to the procedure. I understand that I assume financial responsibility for all services rendered and that payment is due on the date of surgery.

Laser Surgery

Laser surgery results in less pain, less bleeding, less swelling, and reduced risk of infection *

I hereby authorize the use of laser surgery. I understand the cost of laser surgery is $_______ in   addition to the cost of surgery.
I hereby decline the use of surgical laser.

Microchip

Every two seconds, a family pet is lost. Many are never reunited with their families because they cannot be identified. Because of these statistics, we suggest microchips whenever a pet is sedated. HomeAgain chips are known nationwide and have a 24-hour hotline to match chip numbers with the owner’s contact information.

Our records indicate your animal ’s microchip number is:

No microchip?

If your pet does not have a microchip and you wish us to implant one during your animal's procedure, please check this box. The cost of the microchip is $68.00 in addition to the cost of surgery.
I hereby decline the implanting of a microchip.

Section II: Parasite Control

For the protection of all our patients, any pet left for treatment will be inspected for external parasites (fleas, ticks, etc.). If parasites are found, we will apply the appropriate topical treatment at the single dose price. Please list any flea, tick or ear mite medication recently applied

CPR/DNR statement

All patients being treated are required to have an advanced directive in the form of a CPR (Cardiopulmonary Resuscitation) or DNR (Do Not Resuscitate) code. Please select ONE option below. *

I request CPR on my pet if my pet suffers from a cardiac or respiratory arrest. I understand that CPR does not guarantee that my pet will have a favorable outcome. Further, I understand that there are fees associated with CPR that would increase the cost of my pet’s care while the hospital is making every effort to contact me.
I DO NOT want CPR performed on my pet. I have elected to have a DNR order placed on my pet’s record. I understand that my pet will pass away in the event of cardiac and/or respiratory arrest.

I am the owner or responsible agent for the patient, and I have the authority to provide this advanced directive. I am over the 18 years of age. *

I have read and agree

Owner/Owner’s Agent Name *

First

Last

Signature *

Today's Date *

Comment

Surgery Consent Form

Surgery Consent Form

Laser Surgery

Microchip

Section II: Parasite Control

CPR/DNR statement

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