Surgery Consent Form

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Client Information

Name *

First

Last

Email *

Phone number(s) at which owner or agent can be reached today and/or tomorrow *

I consent to receive SMS text messages from The Pet Hospital of Tierrasanta. Msg & data rates may apply. Reply STOP to opt-out. *

Patient Information

Patient Name *

Species *

Breed *

Color *

Age *

Sex *

Weight *

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

I, the undersigned owner or agent of the owner of the pet identified above, certify that I am eighteen years of age or over and authorize the veterinarian(s) at The Pet Hospital of Tierrasanta to perform the above procedures(s). I understand that some risks always exist with anesthesia and/or surgery, including allergic reactions, heart problems and death. I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. My signature on this form indicates that any questions I have regarding the following issues have been answered to my satisfaction:

The reasonable medical and/or surgical treatment options for my pet
Sufficient details of the procedures to understand what will be performed
How fully my pet will recover and how long it will take
The most common and serious complications
The length and type of follow-up care and home restraint required
The estimate of the fees for all services
Any necessary payment arrangements.

I have read and understand the above statement. *

I agree

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 agree to pay a deposit of the below percentage of the estimated fees, assume financial responsibility for the remaining fees, and provide payment via cash, credit card, or check at the time my pet is discharged from the hospital. *

Please list the percentage of the estimated fees you agree to pay as a deposit.

Should unexpected life-saving emergency care be required and the hospital staff is unable to reach me, the staff:

has my permission to provide such treatment and I agree to pay for such services.
does not have my permission to provide such treatment.

Date *

Signature *

Clear Signature

Name

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Surgery Consent Form

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