Surgery/Anesthesia Consent Surgery/Anesthesia Consent Your pet is being admitted to the hospital for completion of services listed on the treatment plan you received from our nursing staff in addition to any services you authorize during the course of their stay. You have the right and obligation to make decisions concerning your pet’s health care. Be assured that we will use modern, safe techniques and medications to help insure a successful outcome. This may include: I.V. catheter placement, fluid therapy, pulse-oximetry, blood pressure monitoring, and pain management protocols to ensure their comfort. There are inherent, unavoidable, assumed risks with any anesthetic procedure. Results cannot be guaranteed. Surgical/Dental Procedure Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Client Name* First Last Email* Please enter the Email address you wish us to send this signed consent form on completion.Phone*Please provide the best phone number to reach you at on the day of your pet's scheduled procedure.Please select.*In the event we need to contact you may we use texting service to reach you at the phone number provided?Yes, you may text me.No, you may not text me.Patient Name* Pet's Name Admission Consent: Please carefully read the following*You certify that you have been informed of the nature of the treatment, anticipated results, possible alternatives, and any serious probable risks. You hereby authorize the staff of Fairhaven Veterinary Hospital to administer a general anesthetic, injectable/oral medications, and perform any surgical procedures/laboratory tests deemed necessary to treat your pet. You recognize that during the course of treatment, unforeseen conditions may require additional or different procedures than those anticipated. Life saving measures may be carried out with your implied consent. You release Fairhaven Veterinary Hospital from any loss or expense these actions might incur, provided such actions are indicated in the normal course of treatment or surgery and are consistent with normally accepted veterinary standards of care.I agree- proceed with the procedureI disagree- do not proceed with the procedurePre-anesthesia blood screening*Pre-anesthetic blood screening is valuable in identifying potentially serious internal problems that may not be apparent on physical exam and may increase anesthetic risk. If your pet does not have current blood work on file we can evaluate a sample in-hospital before today’s procedure. I authorize pre-anesthetic blood screening to be run on the day of procedure. I understand this will incur an additional charge.Labwork performed within the last 30 daysI decline pre-anesthetic screeningFinancial Policy*All services are payable in full at time of pick-up. We accept Cash, Visa, MasterCard, American Express, Discover and CareCredit. FVH also offers a monthly installment plan through PaymentBanc for balances greater than $250 (30% down due at drop-off) , please inquire before treatment has begun. Please select your intended payment method for today's services:CashDebit/Credit CardCare CreditPayment BancElectronic Consent*In the event of unforeseen complications or additional procedures we will make every effort to contact you at today’s emergency phone number you provided on the estimate. You, the undersigned, have read, understand and consent to the above surgery/anesthesia consent agreement. You assume financial responsibility for all charges.I agree to all statements and terms of this consent form. You will be redirected to electronic signature capture and a full copy of this agreement will be emailed to you.PhoneThis field is for validation purposes and should be left unchanged.
