Pet Owner Signature
*
Clear
Authorization and Consent
I am the owner of the animal stated in this form
I am authorized to make a decision and sign this consent
I will pay for the surgical fee and other required tests or treatments
The doctor and the staff explained the surgical procedure including risks, complications, and the recovery
If there are any complications that happened, I will not hold the hospital, veterinary doctor, and staff liable
I authorize the use of anesthesia for sedation of the pet
I consent the veterinarian and the hospital to execute the surgical procedure
Signed Date
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Month
-
Day
Year
Date
What did the pet ingested?
Current Medications
Allergies
Date of Surgery
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Month
-
Day
Year
Date
Surgical Procedure
Address
Email Address
*
example@example.com
Phone Number
Name
*
First Name
Last Name
Breed
Weight
Date of Birth
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Month
-
Day
Year
Date
Age
Name of the Pet
When is the last time the pet eat or drink?
Submit
Should be Empty: