VETERINARY VISION OF ROCHESTER
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  • Home
  • Services
    • Diagnostic Procedures >
      • Examination
      • Standard Diagnostics
      • Advanced Diagnostics
    • Surgical Procedures
  • Referring Veterinarians
    • RDVM Portal - Submit referrals, obtain patient information
    • Request E-Consult
  • Client Education
  • Contact Us
    • Our Doctors
    • Contact Information
    • Refill Request
    • Submit a Referral



veterinary vision Surgical Consent form

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.

Submit

Office Hours

Monday:   8:00 AM – 7:00 PM
Tuesday:  8:00 AM – 7:00 PM
Wednesday:  8:00 AM – 5:00 PM
Thursday: 8:00 AM – 4:00 PM  

In Case of Emergency Contact 

Animal Emergency Center - Rochester
248-651-1788

Animal Emergency Center -Novi
248-348-1788

Veterinary Vision of Rochester

278 E. Auburn Rd                                        24360 Novi Rd
Rochester Hills, MI 48307                     Novi, MI 48375
info@vet-vision.com                 info@vet-vision.com
Phone: 248-402-9844            Phone: 248-402-9844
                                Fax: 248-402-9843
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