Client Name:

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Best Phone Number to reach you at:

Patient Name:

Name

Species:

Breed:

Sex:

Male
Female

Age:

Type of Procedure*

I, the undersigned owner or agent of the pet identified above, authorize the staff of Traverse Mountain Pet Care to perform the above procedure(s). 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 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.

Permission

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

Is your pet receiving any medications at home?

Yes
No

If yes, what medications:

I would like my pet to have a microchip placed ($49):

Yes
No
Already has one

A complete physical exam will be performed on your pet prior to the surgical procedure. However, this may not identify all systemic or metabolic problems. For this reason, your pet will have a pre-anesthetic blood panel to evaluate major organ functions prior to anesthesia. Your pet will also have an IV catheter placed and be given intravenous fluids during the 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 read and fully understand the terms and conditions set forth above.

Signature of Owner:

First Last

Date

Name

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

Surgery Anesthesia Consent

Location

Office Hours

Surgery Anesthesia Consent

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