Owner's name *

First

Last

Email *

Phone I can be reached at today *

Emergency phone number *

Patient's name *

Procedure date *

Name of procedure *

I am the owner/agent of the pet identified above. I am 18 years of age or older and I have authority to give this authorization. *

I authorize

I authorize the performance of the identified procedures and the use of associated anesthetics and other medications *

I authorize

Anesthetic Risks: Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks. The incident of complications from anesthesia is extremely low and we do not anticipate any in your pet but on rare occasions the following can occur 1. Allergic reaction to the anesthetic agents 2. Hear rhythm abnormalities 3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties 4. Just like humans, on very are occasions, general anesthesia can result in death *

I have read and understand the risks

Surgical Risks Include: 1. Infection which may require additional testing and medication at an additional cost 2. Blood clots that can lodge in major organs causing stroke or rarely death 3. Bleeding which if severe may require additional hospitalization and further monitoring 4. Dehiscence of surgical site which may result in additional procedures and costs associated with correction *

I have read and understand the risks

The procedures identified above, the purpose for performing them, and the associated risks have been explained to my satisfaction. I realize that there can be no guarantee as to the pet’s condition or outcome of any procedure. *

I authorize

I also understand that unforeseen conditions may be revealed during the identified procedures, which in the opinion of the attending veterinarian may require more extensive or different procedures or treatments. I understand that reasonable efforts will be made to contact me to explain these procedures and obtain my instructions regarding them. However, if these efforts are unsuccessful. I authorize the performance of any procedures or treatments which are deemed necessary in the professional opinion of the attending veterinarian. *

I authorize

I agree that if I do not pickup my pet after completion of the above procedure, the hospital has the right to send my pet to a shelter after 7 days. I further understand that I will still be liable to pay all these fees incurred including boarding fees for the length of time my pet is in the hospital. *

I have read and understand this policy

I understand that I will be financially responsible for treatment should my pet be found to have fleas while admitted for surgery at Alliston Veterinary Services and authorize the cost of one dose of treatment medication (up to $40.00 + HST). *

I have read and understand this policy

A cancellation fee of $100 will be charged if the procedure is cancelled within 48 hours of the scheduled surgery date *

I have read and acknowledge the cancellation fee

Alliston Veterinary Services (AVS) occasionally features patients on it Facebook and Instagram page. With your permission, we may share your pet’s picture, video or story. We may mention your pet by name, but never the owner’s name. *

I consent to using my pet on social media or website
I do not consent to using my pet on social media or website

Date *

Signature *

Clear Signature

I have read and understand this authorization.

Surgery Consent Form

Surgery Consent Form

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