Surgical Consent Form - Park Veterinary Hospital & Urgent Care

Patient Name*

First Last

Client ID*

Date*

Time of last meal*

: HH

MM

Please list items left with your pet

List all medication(s) your pet is on

Last doses given

: HH

MM

I authorize Park Veterinary Hospital to perform the following procedure(s) on my pet

If Ultrasound:*

Cardiac
Abdomen

Please list vaccines*

Labwork (please list)*

Other procedure (specify)*

**PLEASE NOTE: Pets having surgery, ultrasound, or an IV catheter will have fur shaved at corresponding sites.**

The appropriate anesthesia and pain relief medication will be administered as needed before and/or after the procedure. I realize that there are risks associated with anesthesia and these drugs. I understand that there are certain risks and complications associated with any operation or procedure.

I understand that during the course of the operations or procedures, unforeseen conditions may arise that may necessitate the performance of life-saving procedures at additional cost.

(initial)

I understand that during the course of the operations or procedures, unforeseen conditions may arise, but I do not want life-saving procedures performed.

(initial)

Please select one of the following

I authorize Park Vet Hospital to perform any recommended dental x-rays, extractions, minor oral, or non-oral surgery not listed on estimate WITHOUT contacting me first, up to an amount of $_________ above my estimate or unlimited.
Please contact me to discuss additional recommended procedures, BUT if I am unable to be reached at the contact info provided, please do whatever is necessary to avoid a second anesthetic procedure, up to a total amount of $__________ above my estimate or unlimited.
Please contact me to discuss additional recommended procedures, and if I am unable to be reached at the contact info provided, please do NOT perform any additional procedure that has not been previously discussed.

Amount*

Please contact me after surgery*

Yes
No

Would you prefer*

Email*

Phone*

Signature*

Address:	735 West NC Highway 54 Durham, NC 27713
Phone:	919-344-0428
E-mail:	parklovespets@gmail.com