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| | Surgical Consent Form (Page 1)
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Contact Information: Please list phone numbers you would like us to have for update or emergency purposes.
Phone: _____________________ Name__________________ Time:____
Phone: _____________________ Name: _________________ Time: ____
| Please answer the following questions before surgery:
Was food withheld after 8pm last night? ___ Yes ___ No
Has your pet experienced any coughing, vomiting, or diarrhea in the last week? ___ Yes ___ No
( If so, when: ______________________________)
Is your pet currently on any medications? ___ Yes ___ No ____________________________
| Anesthesia Release
I, the undersigned owner or agent of the owner of the pet identified above, certify that I am eighteen years of age or over and authorize the veterinarian(s) at Swift Creek Animal Hospital to perform the above procedure(s). I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns. My signature on this form indicates that any questions I have regarding the following issues have been answered to my satisfaction. While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I agree to assume financial responsibility for the fees, and provide payment via cash, credit card, or check at the time my pet is discharged from the hospital. Should unexpected life-saving emergency care be required and the hospital staff is unable to reach me, the staff has my permission to provide life saving procedures and as I agree to pay for such services.
X______________________________________________
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