Sunshine AH - Consent for Treatment Form

1

Patient Name

2

Procedure(s)

3

Would you like your pets nails trimmed today (complimentary)

YESNO

4

I understand that unforeseen conditions may be revealed during the procedure that may require more extensive or different treatments. I understand that all reasonable efforts will be made to contact me to authorize any additional treatments. If your pet is having a significant or life threatening complication the treatment that is deemed necessary by the veterinarian will be implemented while we attempt to reach you.

5

If a non-life threatening but unexpected condition is found during your pets procedure how would you like us to proceed?
Please initial one of the following

(Initial) Perform whatever treatments are deemed necessary by the veterinarian and I understand that I will be held responsible for the charges associated with those treatments.
(Initial) I would like a phone call to discuss the findings and associated costs before you proceed, however I understand that if I do not respond within 15 minutes my pet will be woken up from anesthesia and the additional procedures will not be performed.
(Initial) I would not like any additional procedures performed.

6

Please initial each statement below
(Initial)    I understand that I assume financial responsibility for all services rendered.
(initial)    The veterinarian has described the procedures identified in the consent form and has explained to my satisfaction the purpose for performing them and the risks involved with them.
I realize that there can be no guarantee as to the outcome of any procedures.
   I hereby authorize anesthesia/surgery for my pet. I understand that some risks always exist with anesthesia and/or surgery. My signature on this consent form indicates that any questions have been answered to my satisfaction. While Sunshine Animal Hospital provides the highest quality of anesthesia monitoring and surgical services, I understand that there are rare complications associated with any anesthetic or surgical procedure. In particular, I have been advised that there is a extremely small risk of death, complications, or side effects every time an anesthetic is used and that I have been advised of the possibility. I acknowledge these risks and understand that the veterinarians and hospital staff will try to minimize such risks. I will not hold Sunshine Animal Hospital, the veterinarians, or any staff member liable for any complications that may arise.

7

CPR

In the event that TEST should experience cardiac or respiratory arrest while being hospitalized today, do you give consent for resuscitative efforts to be initiated until you can be contacted further and notified of your pets status? By consenting to this service, you are also acknowledging that additional fees may apply. If you are not able to be contacted immediately, resuscitation efforts will be continued to be performed at the doctor’s discretion.

8

Please initial one of the following
I agree to CPR being performed in case of arrest
I elect a “Do Not Resuscitate” status in case of arrest

9

Signature

Clear

10

Date

11

Phone Number

Area Code

Phone Number

12

Additional phone number and/or contact

Area Code

Phone Number

13

E-mail Address* This field is required.

example@example.com