Allen Spay Neuter Surgical Consent
Client's Name*
First Name Last Name
Email*
example@example.com
Phone # where you can be reached day of surgery.*
Area Code Phone Number
Address*
Street Address
Street Address Line 2
City State
Zip Code
Patient Information
Pet's Name*
Species*
Breed*
Color*
Weight (LB)
Medical Data
Surgical procedure(s) to be preformed:*
I, the undersgned owner or agent of the pet identified above, authrorize the staff of SAH to perferm the above procdures.
I understand that some risk always exist with anesthesida and/or surgery and that I am encouraged to discuss any concernes I have about those risks with the attending veterinarian before the procedures(s) is/are initiated.
In case of unforeseen emergencies, the staff may or may not have my permission to proceed with life sustaining procedures?*
Yes I give my permission and understand I am responsible for the cost of these procedures. No I do not give my permission.
When was food last given?*
Acknowledgment, Authorization
I understand that a current rabies vaccination is required*
Yes, My pet is up to date and I have proof with me. No, Please update my pet's rabies vaccination today Please update my pet's Da2ppv+4/Hcpch today
I fully understand that any of the below items I choose will be solely my responsibility, Allen Spay Neuter Assistance will NOT pay for any of these additional services, below.
Please do the following at my treatment cost
In order to maintain the health and comfort of all pets in our hospital, each will be checked for fleas and ticks, when they arrive. If any external parasites are found we will treat your pet with a safe, effective product to be billed to you.
I have read this entire consent form. While I accept that all procedures will be performed to the best of the abilities of the hospital staff, I understand that no guarantee or warranty has been made reguarding the results that may be achieved.
Owner Release*
Yes, I assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as progress exams, radiographs and/or additional surgery due to post-op complications. Yes, I have read and fully understand the terms and conditions set forth above.
Client/Agent Signature*
Clear
Date Signed
Month Day Year
Date
Should be Empty:

Allen Spay Neuter Surgical Consent

Patient Information

Medical Data

Acknowledgment, Authorization