Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Contact Phone Number *

In case of an emergency

Secondary Phone Number

If applicable

Pet's Name *

Today's Surgical Procedure- Please check one: *

If other, please specify

Did your pet eat after midnight last night? *

Yes
No

Was a Cerenia dosage (anti-emetic) given last night? *

Yes
No

CPR: Although extremely rare, should unexpected complications arise during the surgery that cause my pet to go into cardiac arrest, I elect for my pet to have CPR initiated? *

Yes
No

The nature of such service has been described to me to my satisfaction and I realize that no guarantee or warranty can ethically or professionally be made regarding the cure or result. I further recognize that there is an inherent risk of adverse reaction to any medication, including anesthetics, and vaccinations that may be administered to my pet.

I would like my pet to have the following additional procedures while sedated for surgery: *

If other, please specify

Please list medications your pet is currently taking and when they were last given: *

Do you have a preferred pharmacy should there be any medications prescribed that need to be filled elsewhere? *

I agree that Lane Animal Hospital may use images and likeness of myself and my pet(s) for advertising, web content, and social media purposes: *

Yes
No

I understand that I assume financial responsibility for all services rendered, and that payment is due at the time the animal is released. A finance charge of 5% per month plus a $10 monthly billing charge will be computed on all unpaid balances over 30 days. A fee of 33-1/3% will be assessed to all accounts that require outside collection services.

Your signature below constitutes your acknowledgment that (i) you have read and agreed to the above, (ii) the procedure(s) have been explained to your satisfaction and that you have all the information that you desire, (iii) you have had the chance to ask questions, and (iv) you authorize and consent to the performance of the procedure(s) and to the administration of anesthesia.

I agree that I have read through this form and am the owner of the pet. *

Sign here

Surgical Consent

Surgical Consent Form

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