Surgical Consent Form

Name*

First Last

Are you the person responsible for decisions and accounts?*

This person should be the owner on account, responsible for decisions and payments and of legal age.

Yes
No

Email*

Phone number you can be reached at during the surgery?*

Please keep your phone on and be available to answer it while we have your pet in the clinic.

Pet Name*

Date and Time of your appointment*

What surgery is your pet booked for?*

Is there any change in your pets medial condition since we last saw them?*

Do you want their nails trimmed/anal glands/ear cleaned?*

Yes
No

Is your pet on any Medications/Supplements/CBD oil. If yes, What is the names, dose, strength of each and when was the last dose given*

Is your pet aggressive where we need to take extra precaution?*

Do you have pet insurance? If so what's the policy number and company name?*

I understand not to feed my pet after midnight, the night before surgery*

Pocket pets such as rabbits, hamsters, rats, ferrets, etc. should NOT be fasted prior to surgery. Please give food and water as usual and call the hospital if you have any questions.

Yes

I understand I can give water up to the time of the appointment.*

Yes

I understand the procedure protocols*

The nature of such services has been described to my satisfaction, and while I accept all procedures to be done to the best abilities of the professional staff, I realize that no guarantee or warranty can ethically or professionally be made regarding the results or cure. I hereby release Arnold Crescent Animal Hospital and staff from any, and all, liability arising from the surgical procedure(s), to be performed on my pet. In particular, I understand that in the event that the treatment requires the use of anesthesia, that there is a risk of death every time an anesthetic is used.

Yes
No

I authorize the attending doctor to care for my pet*

The performance of the identified procedures and the use of associated anesthetics and other medications. I also understand that unforeseen conditions may be revealed during the identified procedures which, in the opinion of the attending veterinarian, require more extensive or different procedures or treatments. I understand that reasonable efforts will be made to contact me to explain these procedures and treatments and obtain my instructions regarding them. However, if the efforts are unsuccessful I authorize the performance of any procedures and treatments which are necessary in the professional opinion of the attending veterinarian. Additional charges may apply. We will make every effort to keep within the estimate but sometimes procedures take longer than expected or differ from the estimate and the price may vary.

Yes
No

I understand there may be periods of time when my pet could be left unattended at the hospital. There is no staff on the premises overnight, after hours and holidays. Although we are open 7 days a week, we are not a 24-hour facility, or an emergency hospital.*

Yes

I agree to pay a deposit prior to the surgery (if requested)*

Yes

I agree to the clinic fees*

To pay the total as per the estimate given, for the above procedures and related clinic fees. I will pay a deposit prior to the procedure and the balance at the time the pet is discharged and hereby acknowledge my indebtedness for this amount. In the event that the pet referred to above is not claimed by the person giving consent within ten (10) days of completion of treatment and convalescence or of any ancillary services provided by Arnold Crescent Animal Hospital, the pet shall be deemed to have been abandoned, and the Clinic shall be entitled to transfer the pet to an animal shelter or to a third (3rd) party owner. The Clinic waives its lien rights under the Repair and Storage Liens Act. Abandonment does not release me of my obligation for payment of services rendered.

Yes

At times during your pet’s visit, we may take pictures. Your consent here will act as authorization to use these pictures on Arnold Crescent Animal Hospital Facebook, Instagram and social media pages.*

Yes
No

In the last 14 days, have you been in close contact with someone that has been confirmed OR probable positive case of COVID-19?*

IMPORTANT COVID-19 HOSPITAL PROTOCOL: If you are showing signs of cold, flu, or have traveled recently please inform us and we will be happy to reschedule your appointment. To keep our staff and clients safe, we are working on a ONE PERSON PER PET POLICY.

Yes
No

Cancellation Policy*

NO-SHOW for SURGERY time - $60.00. We ask that you to call to cancel no less than 24 hours prior to your scheduled appointment to accommodate other patients. We appreciate your consideration and understanding of this policy.

I agree to the cancellation policy

I agree*

I have read and understand this complete form, any questions and concerns will be noted in the below field

I agree

Any other information we should know?

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