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Owner’s Name *

Pet’s Name *

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I am at least 18 years of age and I am the legal owner of the animal described in this medical record. I am admitting my pet for surgery to be performed by one of the Veterinarians at West Main Animal Hospital .

On which date do you admitted your pet? *

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Primary Phone Number *

Secondary Phone Number

E-mail (optional)

I have received an estimate for my pets surgery and am aware that payment in full is due at patient discharge. I understand that if my female pet is found to be in heat or to have parasites that are transmissible to other animals in the hospital, additional charges will apply (please initial).

In the event I cannot be reached at the numbers above I request: *

The doctors/staff continue with all appropriate medical care as needed.
Discontinue medical care until I can be reached.

Surgical procedure being done:

Location (if appropriate):

Does your pet have a microchip?

Yes
No

What is the microchip number? *

Has your pet eaten this morning?

Yes
No

If yes, Please explain *

Has your pet had morning medications?

Yes
No

list if any *

Does your pet need a prescription refill today?

Yes
No

Please specify

My signature below verifies the following:

A) The diagnosis, medical/surgical care and post surgical care has been described to my satisfaction.

B) A financial estimate has been prepared for me. I understand these expected costs are only estimates and that situations can arise that would alter the actual medical cost.

C) I accept that all medical/surgical procedures involve some risk. I understand that these risks include but are not limited to:

General anesthesia. I realize that some patients may have adverse reactions to anesthesia that may result in permanent injury or death.
Infections can complicate wound healing. I realize that despite all precautions, a small percentage of patients may develop infections. I understand that these patients require additional medical care, which is not covered in my medical estimate.
Unexpected outcomes. I understand that no promises or warranties can be given. I realize that complications can occur at any point during the procedure or the healing process. I accept that some complications can prevent my pet from achieving the outcome I had hoped for.

Signature

Signature of Responsible party

Please discuss the below options with a doctor or technician

My pet’s post surgical care has been discussed with me to my satisfaction and I have chosen: *

Transfer of my pet to an overnight care facility. I accept any risk associated with the transport of my pet. I realize this is an additional cost of care.
Overnight hospitalization will be provided by West Main Animal Hospital. I understand that my pet will be unattended for a portion of their time, and I accept the risk associated with my pet’s hospitalization.
I request my pet to be discharged to my care the day of surgery. I accept full responsibility for my pet’s care once discharged to me by West Main Animal Hospital West Main.

Signature *

Date *

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Surgery Consent Form

Welcome to West Main Animal Hospital

Thank you for selecting our veterinary healthcare team!

Please discuss the below options with a doctor or technician

Ready to Visit?

URGENT cARE

Have A Question?

Location

Contact Information

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Online Form

Surgery Consent Form

Welcome to West Main Animal Hospital

Thank you for selecting our veterinary healthcare team!

**Please discuss the below options with a doctor or technician**

Please discuss the below options with a doctor or technician