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Surgery Consent Form

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Surgery Consent Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before we visit you.

Client Name *

First

Last

Patient Name *

Phone number at which owner can be reached today or tomorrow: *

Additional number

Email *

After procedure:

Would you like us to text you after the procedure, or would you prefer a call? *

Text
Call

Anesthetic and surgical procedure(s) to be performed: *

TPLO (Tibial Plateau Leveling Osteotomy)
Luxating Patella
Fracture Repair
Hip Toggle
FHO (Femoral Head and Neck Ostectomy)
Other procedure

If other, please specify

I, the undersigned owner or agent of the pet identified above, authorize the staff of Richardson Surgical to perform the above procedure(s). *

I have read and agree

I agree that my pet will not be fed anything other than water after 10 pm the night before the procedure *

I agree
I disagree

Any other concerns/allergies/procedures?

I understand that some risks always exist with anesthesia and/ or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. *

I have read and agree

I am over 18 and understand that the attending veterinarian will make every effort to contact me regarding treatment in the case of unforeseen emergencies. If unable to contact me, the staff may or may not have my permission to proceed with life sustaining procedures. *

I give my permission [yes]
I do not give my permission [no]

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 also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow up radiographs, re-check physical exams and additional surgery due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions. I have been provided an estimated cost for the procedure(s) listed above. I assume financial responsibility for the recommended services and will provide payment in full at the time my pet is discharged from the hospital. I have read and fully understand the terms and conditions set forth above. *

I have read and agree

Signature *

Date *

Comment

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Location

16210 N High Desert Street,
Nampa, ID 83687

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Contact Information

P: 208-546-0979
E: [email protected]

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Hours

24 hours

Name *

First

Last

Email *

Phone

How can we help you? *

Phone