Surgery and Anesthesia Consent Form

Please fill out the following form before your scheduled appointment.

Forms

Consent Form

Please fill out the following form as thoroughly as possible before your scheduled appointment. Please note: All * fields are required. If you have any questions, please don’t hesitate to call us.

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Client's Name *

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Pet's Name *

Species *

Breed *

Sex *

Are they spayed/neutered?

Age *

I am the owner or agent for the owner of the above-described animal and have the authority to execute this consent. I hereby authorize the performance of the following procedure(s) or operation(s) *

Sign here

I understand that during the performance of the foregoing procedure(s) or operation(s), unforeseen conditions may be revealed that necessitate an extension of the foregoing procedures (s) or operation(s) or different procedure (s) or procedure (s) or operation (s) than those set forth above. Therefore I hereby consent to and authorize the performance of such procedure (s) or operation (s) as are necessary and desirable in the exercise of Doctor’s professional judgment. *

Sign here

I also authorize the use of appropriate anesthetics and other medications, and I understand that hospital support personnel will be employed as deemed necessary by the attending veterinarian.

I have been advised as to the nature of the procedure(s) or operation(s) and the risks involved. I realized that results cannot be guaranteed.

Do you accept the recommended per-anesthetic blood profile and request that you proceed with anesthesia. (There is a risk with anesthesia and surgery) Additional cost is added. *

I accept
I decline

I understand that Pain Management is given for the elective procedure.

I elect to have an additional pain management package given, and understand that it will be subject to an additional cost.

I have read and understand this authorization and consent. I assume full financial responsibility for this animal. *

Clear Signature

Sign here

Date *

Emergency Phone Number *

While your pet is sedated, would you like us to:

Clean Ears ($20.80)
Express Anal Sacs ($26.52)
Trim Nails ($24.90)
Brush Teeth ($10.40)
Microchip ($45.98)
Hygiene Cut ($10.40)

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Questions?

Contact Us

Please don’t hesitate to reach out by using our contact information or online form below.

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Contact

P: (915) 833-4883
F: (915) 833-4978
E: foothillsanimalclinicep@gmail.com

Address

710 Belvidere St
El Paso, TX 79912

Hours

Mon – Fri: 8:00 AM – 12:00 PM & 2:00 PM – 6:00 PM
Sat – Sun: Closed

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