Pet Information

Pet's Name *

Contact Information

Owner's Name *

First

Last

Email *

Phone *

Additional Phone

Secondary Contact *

First

Last

This person has your authority to consent to medical decisions regarding your pet's surgical care in the event we cannot reach you.

Secondary Contact Phone *

Today's procedure is: (example: lump removal, exam, etc.) *

Additional Services Desired While Patient Is Sedated

Please select any/all that you would like us to provide while your pet is sedated

Please specify the additional service(s) you'd like provided to your pet *

Authorization

I have been advised of the nature of the procedure(s) and/or surgical operation(s) and the risks/potential complications involved. I understand that during the performance of the anesthetic procedure(s) that I have authorized, unforeseen conditions may arise. I am encouraged to discuss any concerns about those risks with my veterinarian before the procedure(s) are initiated. My signature on this consent form indicates that any questions have been answered satisfactorily. *

I have read, understand, and authorize

I authorize Country Lane Animal Hospital to perform any additional diagnostic, treatment, or surgical procedure(s) deemed necessary for medical complications or otherwise unforseen circumstances. I understand there are rare complications associated with any anesthetic procedure. No warranty or guarantee has been given to me as to the results or cure afforded by these treatments or procedures. I fully understand these risks and understand the veterinarians and hospital staff will try to minimize such risks. I will not hold Country Lane Animal Hospital, the veterinarians, or any staff member liable for any complications that may arise. *

I have read, understand, and authorize

Payment due upon services rendered. *

I have read, understand, and agree.

All patients being treated are required to have an advanced directive in the form of a (CPR) Cardiopulmonary Resuscitation or (DNR) Do Not Resuscitate code. CPR is the resuscitation of an animal that has stopped breathing or whose heart has stopped. Please initial ONE option below.

I request CPR (Resuscitation) on my pet in the event that my pet suffers from cardiac or respiratory arrest. I understand that CPR does not guarantee that my pet will have a favorable outcome. Further, I understand that there are fees associated with CPR, which would increase the cost of my pet's care while the hospital makes every effort to contact me. *

INITIAL

I DO NOT want CPR performed on my pet. I have elected to have a DNR (Do Not Resuscitate) order placed on my pet's record. I understand that my pet will pass away in the event of cardiac and/or respiratory arrest. *

INITIAL

Owner/Agent: *

Signature *

Clear Signature

Date *

I am the owner or agent responsible for the patient, and I have the authority to provide this advanced directive. I am over 18 years of age.

Phone

E-mail

Surgery Consent Form