Page 1 of 1

Surgery Procedure Form

Disclaimer

PAYMENT IS REQUIRED IN FULL AT THE TIME SERVICES ARE RENDERED. ACCEPTABLE FORMS OF PAYMENT ARE CASH, AMEX, VISA, MASTERCARD, DISCOVER, CARECREDIT, AND SCRATCHPAY (CHECKS WILL NOT BE ACCEPTED).

Pet Owner Name

Address

Patient Name

Primary contact person

Primary contact phone number

Secondary contact person

Secondary contact phone number

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

Anesthetic & Surgical Consent Disclosure

Authorization and Risk Acknowledgement

I, the undersigned owner or authorized agent, certify that I have the authority to execute this consent. I authorize the veterinarians and staff of West Hills Animal Hospital to perform the scheduled procedure and administer necessary sedatives or general anesthetics. I understand that:
1. Inherent Risks: Any anesthetic procedure involves inherent risks, even in apparently healthy animals.
2. Potential Complications: Rare but possible complications include allergic reactions, cardiac instability (arrhythmias/hypotension), respiratory depression, or acute death.
3. No Guarantees: Veterinary medicine is an inexact science; therefore, no warranty or guarantee of a successful outcome has been stated or implied.
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