Surgical Consent Form

"*" indicates required fields

We place the highest priority on ensuring you feel comfortable with the plan for your pet’s care and fully understand the authorizations below before giving your consent. If you have any questions or need clarification on any of the choices, please contact the hospital so a medical team member can review the form with you prior to completing it. As always, thank you for entrusting us with your pet’s care.

Appointment Date*

Appointment Time*

AM/PM

Client's First Name*

Client's Last Name*

Best Contact Number*

Email*

Pet's Name*

Species*

Canine

Feline

Surgery/Procedure to be performed*

Consent*

I have read and authorize

I hereby consent that the surgery/procedure identified above has been explained to my satisfaction by the veterinarian and that there can be no guarantee as to the outcome of any procedure/surgery.

Consent*

I have read and authorize

I hereby authorize anesthesia/surgery for my pet. While Health and Harmony provides the highest quality of anesthesia monitoring and surgical services, I understand that there are inherent risks associated with any surgical procedure, even in apparently healthy animals. I have been advised that there is risk of complications and in the rarest case, even death. I will not hold Health and Harmony liable for any complications that may arise.

Please select one of the following options*

I authorize the Veterinarian to perform any additional treatments deemed medically necessary. I do not need to be contacted and understand these treatments may incur additional costs higher than discussed in the plan of care.

I request to be contacted should any additional treatments be deemed medically necessary by the veterinarian. If I cannot be reached, I authorize the necessary treatments and understand this may incur additional costs higher than discussed in the plan of care.

Third I request to be contacted should any additional treatments be deemed medically necessary by the veterinarian. If I cannot be reached, do NOT perform any additional treatments not included in the plan of care. I understand this will delay treatment and may require additional appointments in the near future.

In the event of an unforeseen emergency, and your pet were to go into cardiac or respiratory arrest, please indicate what life-saving measures you would like the doctors and medical staff to take by selecting ONE choice below*

Please attempt resuscitation by performing CPR (cardiopulmonary resuscitation). Life-saving measures may include, but are not limited to, external chest compressions, securing an airway, providing oxygen, placing an IV catheter, and administering any necessary medications. I understand that there are additional costs associated with life-saving measures and that resuscitation is not appropriate for every patient that has gone into cardiac arrest.

Please DO NOT perform life-saving measures.

Signature*

Date*

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What's Next

1
Call us or schedule an appointment online.
2
Meet with a doctor for an initial exam.
3
Put a plan together for your pet.

Make An Appointment

What's Next

Call us or schedule an appointment online.

Meet with a doctor for an initial exam.

Put a plan together for your pet.

Where family pets find loving care