Surgery Consent Form

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.

Procedure Date:

In the event we need to contact you, may we use texting service to reach you at the phone number provided?
  • 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.

  • 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.
  • Microchip Placement:
    If your pet is not currently micro-chipped, we can easily provide that service at today's procedure. Microchips are provided through Homeagain and cost includes all registration fees. Microchips last for the lifetime of your pet and provide peace of mind in the event your pet becomes lost. Our microchips now allow for non-invasive body temperature checks at future exam visits using our specially designed universal chip scanners.
  • 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 Scratch Pay for qualified borrowers. To apply prior to your pet's procedure, please visit Please select your intended payment method for today's services:
  • In the event of unforeseen complications or additional procedures we will make every effort to contact you at the emergency phone number you have provided. You, the undersigned, have read, understand and consent to the above surgery/anesthesia consent agreement. You assume financial responsibility for all charges.

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Signature Certificate
Document name: Surgery Consent Form
lock iconUnique Document ID: 298f63a6ead4d93877dc9c519f113990e5001e98
Timestamp Audit
June 22, 2017 3:20 pm PDTSurgery Consent Form Uploaded by Michael Bellis - IP