Page 1 of 1

Surgery Procedure Form

Pet Owner Name

Address

Patient Name

Breed

Age

Weight

Color

Contact phone #

Primary contact person

Emergency Phone #

Emergency contact person

When was the last time your pet ate?

Is your pet on any medication?

Is your pet on any medication?
A
B

What Surgery is your pet here for?

Special instructions

Authorization

I hereby authorize performance of the above surgical procedure. The nature of such service has been described to me to my satisfaction and I realize that no guarantee no warranty can ethically or professionally be made regarding the results or cure.
I understand that I assume financial responsibility for all services rendered, and that payment is due upon hospital discharge of my pet.

Signature of Owner or Authorized Agent

Signature

Date