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Owner Name

Pet Name

Cell Phone

Emergency Phone

Email Address

Would you like us to send you a text picture of your pet after the procedure today?

Yes
No

Is there anything else you would like us to do for your pet today?

Would you like to have your pet micro-chipped while under anesthesia? ($55.00)

Yes
No

Agreement

Surgical Agreement & Authorization:

By completing this form, I authorize The Pet Vet on Patton to perform the above procedures, as well as additional diagnostic, therapeutic, or surgical procedures as deemed necessary by the veterinarian should unforeseen conditions or complications be revealed. I understand that hospital support personnel will be involved in my pet’s care. The nature of the procedures(s) has been explained to me and no guarantee has been made as to the results or cure. I understand that risks exist for any anesthetic or surgical procedure.

Non-Emergency Procedures

If the doctor finds that additional, non-emergency procedures are needed for my pet today:
(Please Mark The One Option That Best Describes Your Wishes)

Proceed with any treatment needed, including dental X-Rays, oral surgery or teeth extractions, or medications administered in the hospital or sent home. I understand additional costs will be involved that could total up to an additional $800.
Do not perform any additional procedures, besides those previously discussed unless you reach me first. I understand that my pet may need to be re-anesthetized at my expense in order to perform the additional procedures in the future.

I understand payment is required on the day services are provided.

I hereby certify that I am the owner or agent for the above named pet.

I have read and understand this authorization and consent form and accept the terms as stated above.

I understand this Consent Form will expire in 60 days.

Today's Date