Surgical Consent Form

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
    (for dispensing controlled drugs)
  • 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
  • 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