Surgery Consent Form
|Estimate given ($)|
⦁ I am the owner, or authorized agent for the owner, of the patient identified above. I have the authority to give authorization and do so voluntarily.
⦁ The procedures identified above have been explained (the purpose for performing them and the risks involved with them) to my satisfaction. I realize that there can be no guarantee as the patient’s condition or outcome of any procedures. In particular, I have been advised 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 and that I have been advised of the likelihood of such occurrence. I authorize the performance of the identified procedures and the use of the associated anesthetics and other medications as indicated.
⦁ I understand that unforeseen conditions may be revealed during the identified procedures, which, in the opinion of the attending veterinary, require more extensive or different procedures/treatments. I understand that all efforts will be employed to obtain my instructions regarding them however, if the efforts are unsuccessful, I authorize the performance of any procedures or treatments, whichever are necessary in the professional opinion of the attending veterinarian.
⦁ I authorize oral administration and associated charges of CAPSTAR if fleas are seen on my pet during the pre-surgical examination. (At a cost of $ 10.00)
⦁ I understand that I have given a phone number at which I can be contacted during surgery if there is an emergency or if any questions arise. I am aware that if any additional procedures are found, but are not medically necessary AND I am unavailable to give consent, that FVAH cannot do the procedure. This means that the additional items will have to be done as part of a second surgery, that is wholly at my own cost.
⦁ If I have declined vaccinations, I understand that my pet is not protected against virus and disease.
|I have read and understand this authorization. (Initials/Signature) (required)|