Claremont Veterinary Hospital

Surgery Authorization Form

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Claremont Veterinary Hospital Surgery Authorization Form

Please fill out the form below as accurately as possible!

Name *

First

Last

Email *

Primary Phone *

That can be reached at today

Secondary Phone

Pet's Name *

Species (dog, cat, etc.) *

Breed *

Sex *

Male
Neutered Male
Female
Spayed Female

Procedures to be performed:

I, the undersigned owner or agent of the owner of the pet identified above, certify that I am the age stated below and authorize the veterinarians at Claremont Veterinary 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 I have about those risks with the attending veterinarian before the procedure(s)is/are initiated. While I accept that all procedures will be performed to the best of the abilities of the staff at this facility, I certify that no guarantee or warranty has been made regarding the results that may be achieved. I agree to pay a deposit of 50% of the estimated fees. I agree to assume financial responsibility for the remaining fees and will provide payment via cash or credit card 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 should follow my permission stated below to provide such treatment and I agree to pay for such service. I understand that during the performance of medical, surgical, or anesthetic procedures, unforeseen conditions may be revealed that necessitate more extensive, costly, or different procedures than originally planned. If staff at this veterinary practice are unable to reach me, I hereby consent to and authorize the performance of such procedures as are necessary and desirable in the professional judgment of the attending veterinarian, provided that the cost for such additional procedures will not increase the total fee by more than 25% of that provided in the estimate for these procedures. *

I have read and accept the financial policy.

Please check one:

I, the owner am above the age of 18.
I, the owner am under the age of 18

Please check one:

The staff has my permission to provide such treatment and I agree to pay for such service
The staff does not have my permission to provide such treatment and I agree to pay for such service

PLEASE NOTE: ANY PET ADMITTED WITH EVIDENCE OF EXTERNAL PARASITES (FLEAS, TICKS, ETC.) WILL BE TREATED AT THE OWNERS EXPENSE. VETERINARY SERVICE DURING NIGHTTIME HOURS, SOME DAYTIME HOURS AND/OR WEEKENDS IS PROVIDED AT THE DISCRETION OF THE VETERINARIAN IN CHARGE. CONTINUOUS PRESCENCE OF PERSONNEL MAY NOT BE PROVIDED DURING THES HOURS.

Signature *

Clear Signature

Date / Time

Message

Surgery Authorization Form

Claremont Veterinary Hospital Surgery Authorization Form

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