This form is for patients with a currently scheduled surgical appointment. 

    Client Information 

    Surgical Consent

    ​I, the undersigned, do hereby certify that I am the owner (or authorized agent of the owner) of the above described animal, and I authorize the performance of diagnostic, therapeutic, anesthetic, surgical and preventative procedures described in the estimate or emergency procedures as may be deemed necessary by the veterinarian.
    I have been advised as to the nature of the procedures or operations and of the risks involved. I realize that surgical results can not be predicted or guaranteed. I understand that complications or concurrent medical issues may arise and that the fees associated with treatment of such issues are not included in the estimate I was given, but are costs I may be responsible for above and beyond the estimated price.

    In the event the clinic is not staffed or if overnight or weekend observation by a veterinarian is required, I authorize the transfer of my pet to the emergency clinic for observation and treatment. I understand that I will be billed by the emergency clinic at a rate dependent upon the care required and those charges are in addition to the estimate quoted to me.

    By signing below I acknowledge that the technician assisting me today has reviewed the surgical estimate previously provided to me to my satisfaction. I understand the estimate quoted may vary, depending upon the extent of treatment required. A veterinarian or member of the staff will make reasonable efforts to notify me prior to any additional treatment when the actual cost is expected to exceed this estimated by 10% unless the additional treatment is required as an immediate life saving measure.

    I have discussed and indicated with the technician any recommended treatments and/or services that I am declining. These procedures have been strongly recommended by the veterinarian and I am aware that I am declining the procedures against medical advice by initialing individual items.

    I understand that full payment for services is due at the time of discharge. I have read and understand this authorization and consent.