Patient Admission Client Consent Form - Surgery

Owner and Pet Information

Pet's Name*

Preferred Contact Number for Today's Date*

Alternate Contact Number for Owner or Co-Owner*

I authorize Companion Pet Hospital to perform the following tests or procedures as advised in the best interest of my pet:*

Please describe in your own words to the best of your ability.

When did your pet last receive flea, tick, and heartworm prevention?*

Please note that if fleas are found on your pet today, they will be treated at your expense.

General Instructions

If your pet is having sedation or anesthesia, do not feed your pet past midnight the night before the procedure.

In general, it is okay to allow access to water overnight, but pick up your pet's water dish in the morning.

If your pet takes medicine, CHECK WITH YOUR VET about whether or not you should administer the dose on the morning of the procedure. 

If your pet is coming in for diagnostic testing (such as blood work or an ultrasound) please do not feed on the morning of the test unless your vet instructs you otherwise.  If in doubt, CHECK WITH YOUR VET

Please Read and Initial Each of the Four Statements Below.

The services to be performed have been described to me and I had the opportunity to ask questions.  I accept all procedures will be done to the best of the abilities of the professional staff, and I realize that no guarantee can be made regarding the results or cure.*

I have been provided with an estimate for today's services, which was prepared to the best of the ability of the Companion Pet Hospital team.  I accept responsibility for all fees that may incur while my pet is in the care of CPH. I understand that a deposit of 50% of the high end of the fee range is required in advance. I agree that full payment, less applicable deposit, is expected at the time of discharge.*

I authorize the use of appropriate sedatives, anesthetics, and/or other medications, and I have been advised potential risks, including but not limited to hemorrhage, infection, and death. I understand that patients that require general anesthesia will receive appropriate pre-operative testing, monitoring, and post-operative care in compliance with the AAHA (American Animal Hospital Association) standards of care.*

I understand that unforeseen conditions may be revealed that necessitate additional medical care at an additional cost that shall be at my sole expense. I understand that reasonable attempts will be made to contact me if expected fees will exceed estimated cost, however I do consent to the performance and costs of any procedure that, in the doctor’s professional judgment, is deemed immediately necessary for my pet's wellbeing.*

Procedure Consent

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Patient Admission Client Consent Form – Surgery

Owner and Pet Information

General Instructions

Please Read and Initial Each of the Four Statements Below.

Procedure Consent