Name *

First

Last

Date *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Pet's Name *

Species *

Breed *

Sex *

Male
Neutered Male
Female
Spayed Female

Age/Date of Birth *

Weight

Color/Markings

I, being responsible for the above-described animal, have the authority to grant you my consent to receive, prescribe for, and treat and/operate upon this animal. *

I consent

I understand that the surgery or treatment contemplated is: *

I understand that before anesthesia or surgery, it is sound medical procedures to perform a complete blood count/chemistry on the animal for the purpose of discovering subclinical infections, inflammatory processes, anemia, or blood clotting disorder. In the case surgery or anesthesia, (please choose one) *

I DO wish a complete blood count/chemistry performed on my animal, at additional cost.
I DO NOT wish a complete blood count/chemistry performed on my animal.

Although pain will be controlled by sedation or anesthesia during and immediately after procedure, post operative pain can significant impact the overall health and well being of your pet. If your animal licks or chews at the surgical incision, a special collar may be required to prevent this. *

I DO want additional pain medication sent home for my pet at additional cost.
I DO NOT want additional pain medication sent home for my pet.

If a tumor was removed, I would like a histopath performed. *

Yes
No

I would like a microchip implanted in my pet for identification purposes. *

Yes
No

You are to use all reasonable precautions against injury, escape or demise of the animal, but you will not be held liable or responsible in any manner whatsoever under any circumstances on account of the care, treatment or keeping of the animal described above otherwise in connection therewith. It is thoroughly understood that I assume all risks. *

I understand the above

I understand that if the animal is not current on vaccinations for rabies, this will be done during hospitalization and added to the cost the above-described procedures. *

I understand the above

I also understand that unforeseen circumstances may make it advisable that other surgery or treatment be done and I authorize other surgery or treatment when and if it is deemed advisable. *

I understand the above

Follow up treatment or exams are not included in the initial fee estimate. Received estimate? *

Yes
No

I consent to the administration of such anesthesia as may be deemed proper by the doctor.

I acknowledge that no assurance or guarantee has been made of the result of surgery or treatment and that risks and probabilities complications exist in any surgical or medical treatment.

All charges including boarding costs shall be paid when the pet is released from the hospital. If the pet is not called for within 12 days after the time specified for return and if the doctor is not notified in writing of an alternate date within the 12 day period, the animal will be considered abandoned and may be disposed of as the doctor sees fit. It is understood that you so doing does not relieve me from paying all costs of your services and use of your hospital including the cost of boarding.

I understand that if my animal is in the hospital overnight or on the weekends, 24 hr supervision and monitoring is not provided.

If your pet is to be spayed or neutered, a small green tattoo will be applied to the caudoventral abdomen to signify this surgery has been performed.

After carefully reading the above, I have signed an agreement.

Clear Signature

(Signature of owner or owner’s agent)

Informed Consent Form

Informed Consent Form

We proudly serve the pets in Hewitt, TX and beyond.

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