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Surgery

Home Surgical Consent Form

Surgical Consent Form

Owner's Name

First

Last

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Phone Number

Email

Pet's Name

Species

Breed and Sex

FOR ALL PROCEDURES:

Additional services requested may result in additional fees

Homeagain Microchip

Yes

No

Initials

If you select NO, please enter your initials to acknowledge.

Nail Trim

Yes

No

Initials

If you select NO, please enter your initials to acknowledge.

Ear Cleaning

Yes

No

Initials

If you select NO, please enter your initials to acknowledge.

Hidden

Anal Glands

Yes

No

Initials

If you select NO, please enter your initials to acknowledge.

My pet is current on heartworm prevention and has not missed any doses

Yes

No

Initials

If you select NO, please enter your initials to acknowledge.

CONSENT

I am the owner or agent for the owner of the above described animal and have the authority to execute this consent. I hereby consent and authorize the performance of the following procedure(s) or operation(s):

I understand that during the performance of the foregoing procedure(s) or operation(s), unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure(s) or operation(s) or different procedure(s) or operation(s) than those set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) or operation(s) as are necessary and desirable in the exercise of the veterinarian's professional judgment. I also authorize the use of appropriate anesthetics and other medications, and I understand that hospital support personnel will be employed as deemed necessary by the veterinarian. I have been advised as to the nature of the procedure(s) or operation(s) and the risk involved. I realize that results cannot be guaranteed. I understand that If my pet is pregnant or in heat there is an extra charge. I have read and understand this authorization and consent.

Signer Name

First

Last

Signature

FOR DENTAL PROCEDURES:

I want my pet to have any loose or infected teeth extracted while my pet is under anesthesia. I understand that extractions are an additional cost.

Yes

I authorize up to $___ above the high end of the estimate.

Call first before doing any extractions. If I cannot be reached, nothing will be done.

Call First

No, I do not want my pet to have any loose or infected teeth extracted while my pet is under anesthesia. I understand the risks if these teeth are not extracted.

No

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913 1st Ave N.,
St. Petersburg, FL 33705

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Pet Portal

913 1st Ave N.,
St. Petersburg, FL 33705

Home
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Business Hours

Mon

7:30 am - 6:00 pm

Tues

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Wed

7:30 am - 6:00 pm

Thu

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Fri

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Sat

Closed

Sun

Closed

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