Client Details

Name *

First

Last

Email *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Phone *

Animal Details

Pet Name *

Species *

Breed *

Age *

Sex *

Male
Female

Weight (kg) *

Your pet has been admitted for a surgical procedure.

The surgical procedure will be performed under general anesthesia and your pet will be monitored closely while under anesthesia.

The risk of complications for routine sedation/anesthesia in animals who are otherwise healthy is extremely low, and we will take every precaution to avoid complications. Many of these complications are self-limiting and reversible. However, we cannot rule out the risk of more serious and unforeseen complications. The potential complications during and following sedation/anesthesia include but are not limited to adverse reactions to the drug(s), including gastrointestinal upset, and drastic changes in blood pressure which may result in reversible or irreversible organ damage, aspiration pneumonia, respiratory-cardiac arrest, and death. Also, the potential complications for any kind of surgery include but are not limited to bleeding, infection, and delayed healing of skin or other tissues involved in the operation.

I authorize the performance of the above procedure and the use of associated medications. I also understand that if unforeseen complications occur during the above procedure, the attending veterinarian(s) may need to use more extensive or different procedures to reverse the unwanted complications. I understand that reasonable efforts will be made to contact me to explain these procedures and treatments and obtain my instructions regarding them.

However, if the efforts are unsuccessful, I authorize the performance of any procedures or treatments which are necessary in the professional opinion of the attending veterinarian(s).

Health Questionnaire

Has your pet eaten after midnight (12:00 AM) last night? *

Yes
No

known the after

Has your pet had previous anesthesia? *

Yes
No

Were there any complications? *

Is your pet on any medication? *

Yes
No

What kind of medication? *

The medication was it given today? *

Yes
No

Has your pet been eating and drinking normally? *

Yes
No

Any other known health problems? *

Yes
No

Please specify the health problem *

If the female is intact, is she in heat? *

Yes
No
N/A

Please select accept or decline for each of the following:

I would like blood tests performed prior to anesthesia *

Accept
Decline

(checks basic organ function - kidney, liver, blood glucose - to ensure your pet can safely undergo anesthesia)

I would like my pet microchipped *

Accept
Decline

I would like my pet to receive a complimentary nail trim *

Accept
Decline

Hospitalization & Emergency Instructions

In the event my pet requires hospitalization beyond the first day: *

I understand that I will be required to transfer my pet to a 24 hour veterinary hospital for continued care at my own expense.

In the event of cardiac arrest, respiratory arrest, collapse, or unconsciousness: (Please select one of the following) *

I wish the staff to perform resuscitation (CPR) on my pet. I am aware that there will be additional costs associated with CPR.
I DO NOT wish the staff to perform resuscitation (CPR) on my pet. I understand that if my pet suffers from cardiac arrest, respiratory arrest, collapse or unconsciousness, that if CPR is not performed, my pet will pass away (DNR).

Final Consent

Final Consent *

I agree to meet the costs of all treatment at the time of discharge. I understand the risks and complications of these procedures, which have been explained to me by the Veterinarian. All accounts are payable at the time of consultation unless a prior arrangement has been made.

Final Consent 2 *

I, the undersigned owner or agent of the pet identified above, am 18 years of age or older, and authorize the veterinarian(s) at Campbellville Animal Hospital to perform the above procedure(s).

Signature *

Clear Signature

Witness Signature *

Clear Signature

Hours

Surgery Consent Form

Client Details

Animal Details

However, if the efforts are unsuccessful, I authorize the performance of any procedures or treatments which are necessary in the professional opinion of the attending veterinarian(s).

Health Questionnaire

Please select accept or decline for each of the following:

Hospitalization & Emergency Instructions

Final Consent

Make an Appointment

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Location

Contact Information

Hours