Surgery Consent Form

Complete your surgery consent form online!

Owner's Name *

First

Last

Owner's Email *

Owner's Phone *

Pet's Name

Pet's Breed

Pet's Age/Date of Birth

I am the owner (or authorized agent of the owner) of the animal described above, and have the authority to execute this consent. *

I have read and agree.

I acknowledge that my pet is scheduled for an anesthetic procedure. I have been informed that advances in anesthesia and anesthetic monitoring techniques have made routine procedures relatively safe, with low rates of complications. However, I understand that occasionally problems can occur due to pre-existing conditions that are not evident during routine histories and physical examinations. I understand that some risk always exists with anesthesia, even in apparently healthy animals, including the possibility of death. I have discussed my concerns with the veterinarian and understand that it may be necessary to provide additional medical or surgical treatment to my pet in the event of unforeseen circumstances. I realize that no guarantee, legal or ethical, can be made to me regarding the outcome of any procedure performed. I hereby authorize the use of anesthetics and other medications, as well as any such additional treatment, as deemed necessary by the veterinarian. I understand that hospital personnel will be employed in treating my pet. I have carefully read, and fully understand, this consent. The fees associated with these services have been explained to me, and I agree to pay such fees at the time my pet is released from the hospital. *

I have read and agree.

To minimize problems the doctors and staff at Chester Valley Veterinary Hospital have recommended that my pet be screened prior to anesthesia. *

I Consent to the recommended pre-anesthetic diagnostics
I Decline to the above recommended pre-anesthetic diagnostic test and in the absence of negligence, agree to hold the attending doctor(s) and staff at Chester Valley harmless for any untoward anesthetic, surgical, or medical complications that might have been detected and avoided had these tests been performed.

Has your pet had any medications today? *

Has your pet had any food or treats in the past 12 hours?

I hereby certify that I am the owner or authorized agent of the above-named animal and have the authority to execute this consent. *

I have read and certify.

Signature *

Today's Date *

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