Surgical Consent Form

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
    (for dispensing controlled drugs)
  • Only applies to General Anesthesia.
  • For our Diabetic patients, please fill out the following:

  • Please Read and Respond

  • Please Sign or Initial
  • Please Sign or Initial
  • Please Sign or Initial
  • Procedural Risks Acknowledgment

    Risks of the procedure(s) include (but are not limited to) the following: 1. Anesthetic or sedation complications including death 2. Infection 3. Prolonged effects of anesthesia or sedation
  • Please Sign or Initial
  • Please Select One
  • The invoice total may vary 15% to 20%. A deposit is required at the time of drop-off. -This estimate you were given is only for services and does not include any other visits. I understand that visits following surgery will have their own fees which are due at the time of service. -I understand that I was given only an estimate of services. We want to give your pet the best possible care. In order to do so, we sometimes must run tests or procedures that we did not anticipate. We will do our very best to inform you of any additional tests and their costs before performing any unexpected but necessary procedures. -While the potential for anesthesia associated risks is quite low, serious and life threatening complications can arise associated with general anesthesia. I understand that anesthesia as described in this estimate is necessary for this procedure and I understand the risks and complications associated with anesthesia and the surgical procedure(s). -I understand that I am responsible for all medical expenses relating to the care of my pet in this hospital regardless of the eventual outcome. I will assume any attorney fees or collection costs resulting from my failure to pay these fees. -I am the owner or agent of the above described animal and I fully understand the terms of this agreement. Furthermore, I authorize Animal Eye Care to perform the above indicated services. -I understand that a $200 deposit is required at the time the surgery is scheduled. This deposit will be applied to the surgical invoice the day of surgery. I also understand that the deposit is non-refundable unless the surgery is canceled within 72 hours of the scheduled day. -I understand that a 50% deposit is required the morning of the procedure/surgery. -This medical treatment plan and associated cost estimate is valid for 30 days.
  • Payment Acknowledgment

    Payment may be made in the form of cash, personal check, VISA, or MASTERCARD. A fee of $35.00 will be added payable charges for returned checks. The balance must be paid in full before the animal will be released, as our policy does not permit delayed payments.
  • Date Format: MM slash DD slash YYYY
  • Please Sign or Initial