Surgery Authorization Form Explore Surgery Authorization FormOwner Name(Required) First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Patient/Pet(Required)Breed(Required)Sex(Required)Color(Required)Age(Required)Date(Required) MM slash DD slash YYYY Consent(Required) I, being responsible for the above described animal, have the authority to grant my consent to receive, prescribe for, treat and/or operate on my pet. I understand the surgery or treatment contemplated.You are to use all reasonable precautions against injury, escape, or death of my pet, but you will not be held liable or responsible in any matter in connection therewith as it is thoroughly understood that I assume all risks. All charges, including boarding cost, shall be paid upon release from the hospital. If the animal is not called for within 3 days after the time specified for return, and if the doctor is not notified in writing of alternate date within the 3 day period, the animal will be considered abandoned and may be disposed of as the doctor sees fit. It is understood that this does not relieve me from paying for all costs of your services including the cost of boarding and any additional charges that may occur.Pre-OP blood work? I am aware of the additional costs associated with this procedure.(Required) Accept Decline Dr’s DiscretionPain medicine? I am aware of the additional costs associated with this procedure.(Required) Accept Decline Dr’s DiscretionIs your pet currently on any medications(Required) Yes NoIf so, what?Is your pet current on vaccinations?(Required) Yes NoIf not current, would you like them vaccinated at this appointment?(Required) Yes NoI request the following add-on services to be performed with my pet's procedure: E-collar Microchip Anal gland expressionPlease choose one of the following for dental procedures: I permit the extraction of any teeth as the Dr. deems necessary. Wolf Teeth (Equine Only) I wish to be notified before the extraction of any teeth.I can be reached at this phone number this morning** If you can not be reached at this phone number, the doctor will perform the procedure that is medically necessary for you animal and you will be responsible for the charges.**Signature(Required)CAPTCHAΔ
