Surgical Consent Form | Walnut Cove Veterinary Hospital

Surgery Consent Form

Walnut Cove Veterinary Hospital

First name

Last name

Pet Name:

Species / Breed:

Age

Sex:

Male

Female

Neutered / Spayed

Date of Procedure:

Month

Day

Year

Procedure Information

Proposed Procedure(s):

Reason for Procedure(s):

Anesthesia & Risk Acknowledgment

I understand that general anesthesia and/or sedation will be required for the above procedure. I acknowledge that all anesthetic and surgical procedures carry inherent risks, including but not limited to allergic reactions, complications, or, in rare cases, death.

Select One:

I authorize recommended pre-anesthetic bloodwork.

I decline bloodwork and understand the associated risks.

Pre-Anesthetic Testing

Pre-anesthetic bloodwork helps identify underlying conditions that may affect anesthesia safety.

I authorize recommended pre-anesthetic bloodwork.

I decline bloodwork and understand the associated risks.

Emergency Authorization

In the event of unforeseen complications, I authorize the veterinarian to provide any necessary medical treatment deemed in the best interest of my pet.

Yes, provide necessary treatment

No, do not exceed the agreed-upon procedure

Consent & Release

I certify that I am the legal owner or authorized agent of the above-named pet. I authorize Walnut Cove Veterinary Hospital to perform the procedure(s) listed above. I understand the nature of the procedure, its risks, and that no guarantee has been made as to the outcome.

Signature

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Date and time

Month

Day

Year

Time

HoursMinutes

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